Every finding on record at The Palms Nursing & Rehabilitation

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Tylenol #4 300/60mg was received and counted appropriately by LVN A, when hospice delivered medication the resident to the facility. This failure could place residents at risk of pain. Findings include: Record review of Resident #1's face sheet, dated 6/8/2026, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had medical diagnoses which included other specified renal tubal-interstitial diseases (inflammation affecting the kidney's tubules and surrounding tissues), magnesium deficiency, irritable bowel syndrome (chronic gastrointestinal disorder), muscle wasting (gradual decrease in muscle mass, strength, and function of the muscle), abnormal gait and mobility, alcohol induced pancreatitis (inflammation of the pancreas due to alcohol), and cardiomyopathy (enlarged, thickened, or stiffened heart).Record review of Resident #1's quarterly MDS assessment, dated 5/21/2026, revealed Resident #1 had a BIMS (Brief Interview Mental Status) score of 15, which indicated normal thinking and memory. Resident #1 received hospice services and received opioids for pain.Record review of Resident #1's, undated, care plan, revealed Resident #1 had almost constant pain with pins and needles to her fingers and feel as well as neck and back pain, S/P spinal fusion. Potential from pain due to history of pain and impaired mobility chronic pain due to history of pain and impaired mobility. Resident #1's care plan also revealed the goal is for the resident to be comfortable with pain effectively managed. The intervention for Resident #1 included for the resident to be administer medication as ordered: routine Lyrica, PRN Cyclobenzaprine, Acetaminophen with Codeine.Record review of Resident #1's physician orders, dated 6/8/2026, included Tylenol #4 300/60mg by mouth every 4 hours as needed for Pain. Resident #1's physician orders revealed Resident #1 was assessed and started services with hospice on 4/27/2026.During an interview with Resident #1 on 6/9/2026 at 11:32 a.m., Resident #1 revealed she had some issues with pain before she started receiving hospice services in April 2026, but she could remember she hasn't had any unresolved pain since then. Resident #1 was aware there were some issues with her medication but she never had pain because she had several different pain medications.During an interview on 6/8/2026 at 1:30p.m., LVN A verbalized she was working on 5/19/2026 when a hospice nurse delivered medication for Resident #1. LVN A stated she was the manager on the floor and was passing medication and did not take the time to stop and count the medication that was in the bag provided by the hospice nurse. LVN A stated she was told by the hospice nurse narcotics were in the bag, and she locked them in her 2300 hall medication cart but again did not stop to count or make a log sheet for the medication. LVN A stated she proceeded to work her shift and when LVN B came to relieve her, she and LVN B counted the narcotics in the drawer and signed everything off but did not open the bag at this time and count. LVN A stated she left the cart with LVN B and thought everything was accounted for at the end of her shift. LVN A stated she never saw the bag after this day.During an interview on 6/8/2026, at 4:30 p.m., LVN B verbalized she did come on shift on 5/19/2026 and took over the 2300 medication cart for LVN A. LVN B stated when taking over the medication cart she counted all items in the cart but did not remember a bag of narcotics and did not count or see any medication from hospice. LVN B stated she was only working a short shift this day due to a schedule change and did one medication pass and completed her shift and left for the day. LVN B stated it was policy to count narcotics when they arrived with another licensed nurse, make a log sheet and lock them up in the narcotic lock box. During an interview on 6/8/2026 at 2:14 p.m., the hospice nurse stated she delivered Tylenol #4 300/60mg with a count of 45 pills to LVN A and this staff member signed for the medication and multiple other medications on 5/19/2026 for Resident #1. The hospice nurse stated she was called for a refill for the medication on 5/26/2026 and told the facility it was delivered on 5/19/2026 and that it was too soon for a refill.During an interview on 6/9/2026 at 8:30a.m., the Director of Nursing (DON) stated she was notified by the ADON the narcotic medication, Tylenol #4 300/60mg, was missing on 5/26/26. The DON stated we were notified by hospice a refill of the medication was delivered on 5/19/2026. The DON stated she and the ADON immediately started trying to locate the medication, started an investigation to find out what happened, and reported the missing medication to the Administrator. The DON stated the investigation revealed LVN A took possession of a bag delivered by Hospice on 5/19. The DON stated LVN A was informed the bag contained narcotics and LVN A signed for the medication without counting the medication. The DON stated she was told LVN A locked the medication up in the 2300 medication cart but did not count or log the medication per policy. The DON verbalized the investigation which included interviewing staff, calling hospice, placing staff on suspension, doing in-services on narcotic medication, reviewing Resident #1's entire clinical record, reviewing narcotic logs, and providing support to leadership during the process of investigating. The DON stated it was expected for staff to count all narcotics upon delivery, to make a log sheet and lock up all narcotics immediately and follow the policy.During an interview on 6/9/2026 at 3:45p.m., the Administrator stated he was made aware the narcotic medication labeled Tylenol #4 300/60mg with a count of 45 pills was missing on 5/26/2026, by the DON. The Administrator stated the DON informed him she and the ADON were already auditing carts and looking for Resident #1's medication. The Administrator stated he notified the police, Resident #1's family and the resident, and reported to HHS as required and started the investigation. The Administrator stated the DON informed him Hospice delivered a bag of medication to LVN A on 5/19/2026 and LVN A reported to the DON that she locked them in the medication cart without counting or verifying the medication in the bag. The Administrator stated policy and procedure were not followed, and staff should have opened and counted with whoever delivered the medication and logged them appropriately. The Administrator stated the staff no longer worked at the facility and quit the day the investigation was initiated. The Administrator stated the resident was never in pain because she was never out of medication. The investigation did not result in finding the medications.Record review of the facility provided, undated, policy Controlled Substances, revealed 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record for each controlled substance in the presence of a second facility nurse. If there is not a count sheet available with the controlled substance delivered one is to be made immediately upon receipt of medication with the signature of 2 facility licensed nurses.

Based on interviews, and record review the facility failed to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of six residents reviewed. The facility did not develop a measurable and individualized care plan to address Resident #1's falls. This failure could place residents at risk for unmet medical, nursing, mental, and psychosocial needs and preferences. Record review of face sheet dated 12/18/2025 revealed Resident #1 was last admitted on [DATE]. Resident #1's Face sheet also revealed admission and Primary Diagnosis as Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgement and behavior). Record review of the MDS Assessment Summary dated 11/02/2025 revealed Resident #1 had a Brief Interview for Mental Status score of 00 which indicated severe mental impairment. The MDS also revealed Resident #1 had disorganized thinking and requires assistance for activities of daily living to include assistance of supervision for dressing and clothing changes, partial assistance with showers, and assistance with set up for personal hygiene tasks. Record review of care plan, undated, revealed Resident #1 was mobile using a wheelchair and walker. The care plan also revealed Resident #1 was independent for transfers tasks. The care plan also indicated Resident #1 was a fall risk due to her history of falls, impaired cognition, safety awareness, unsteady gait requiring use of walker, and other indicators with interventions of keeping the bed in low position, keeping the call light in reach, keeping the floor clean, dry, and clutter free, to intervene with resident to minimize or reduce fall occurrences (did not indicate how to minimize or reduce fall occurrences), monitor for complaints of dizziness, drowsiness, weakness, and not feeling well, monitor medication effectiveness, provide adequate staff assistance and support for tasks, and should fall occur, nurse to assess resident and notify the doctor and resident representative. The care plan did not include a measurable objective or individualized way to prevent Resident #1 from falling. Record review of Incident Report dated 12/13/2025 indicated Resident #1 had a witnessed fall from her wheelchair with a history of 2 other falls in the last 3 months. The report indicated Resident #1 cannot verbalize coherently and was assessed immediately by RN C. The report indicated Resident #1 was attempting to pick up a blanket from the floor and fell forward out of her wheelchair. The report indicated Resident #1 had two hematomas (a collection or pool of blood that forms outside of blood vessels appearing as a localized lump or bruise where blood has leaked and clotted in tissues or body spaces) to her forehead and the doctor ordered to send Resident #1 to the emergency room for further evaluation. On 12/19/2025 at 10:00 a.m., observation of Resident #1 as she pushed a wheelchair down the hallway with RN C monitoring the hallway. Resident #1 was unable to answer questions when asked. Resident #1 In an interview on 12/18/2025 at 12:20 p.m., MA B stated Resident #1 does fall due to wanting to get out of her wheelchair and not having personal safety awareness. MA B stated the staff redirect Resident #1 the best they can and try to keep her active. MA B stated Resident #1 may have future falls because the facility does not want to restrain her. MA B stated she does not think Resident #1 is abused but also stated she is not sure what else the facility can do to help her not fall. In an interview on 12/19/2025 at 10:15 a.m., the DON indicated Resident #1 does have some minor instances of balance loss and stated her care plan does not reflect specific interventions needed to prevent falls for Resident #1. The DON stated the facility cannot provide 1:1 care for this resident and has spoken with Resident #1's representative and they have not been able to find a good intervention or solution. The DON stated she has recommended Resident #1 may be a good candidate for a different facility, but the family did not agree. In an interview on 12/19/2025 at 11:05 a.m., the Administrator stated he is aware that Resident #1 is a fall risk and has had multiple falls. The Administrator stated Resident #1's family blocks them from transferring the resident to a different facility with a locked unit. The Administrator stated she may need to be transferred out of the facility and will discuss this with the DON. In an interview on 12/22/2025 at 11:00 a.m. Case Manager A of Resident #1's hospice provider stated she has spoken with the facility staff and with the resident's family member regarding Resident #1's falls. Case Manager A stated the facility has been trying different interventions, but it has been difficult due to Resident #1 most likely needing a locked memory care and being unable to find a place that is a good fit for her. Case Manager A also stated Resident #1 is [AGE] years old and susceptible to falls, but they did not want her to be restrained using medication and they want to ensure the Resident is safe. Case Manager A stated she did not think Resident #1 was abused or neglected at this time. In an interview on 12/22/2025 at 1:27 p.m., RN C stated Resident #1 has dementia and is not redirectable. RN C stated they try to keep an eye on her and they do as much as they can for Resident #1. RN C stated they are not staffed to provide 1:1 care for Resident #1 but they almost provide that much supervision for her. RN C stated she has worked with Resident #1 for over a year and does not know what other interventions would help. Unsuccessful attempts to contact family of Resident #1 were made at 2:00 p.m. on 12/18/2025 and 12/19/2025.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #4) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #4's right to be free from verbal abuse when CNA-C made an insulting and ridiculing comment toward Resident #4 on 10/25/2025. This failure could place residents at risk for psychological harm or injury.The findings included: Record review of Resident #4's face sheet, dated 12/03/2025, revealed a [AGE] year-old female with an original admission date of 10/28/2013, and a current admission date of 02/05/2025. Resident #4's diagnoses included Neuromuscular Dysfunction of the Bladder (commonly referred to as neurogenic bladder, occurred when nerve damage impaired bladder control), Obstructive Uropathy (a condition characterized by a blockage in the urinary system which impeded normal urine flow, potentially leading to kidney damage and other complications), Metabolic Encephalopathy (a brain dysfunction leading to symptoms like confusion, memory loss, and altered consciousness), and Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone that regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body). Record review of Resident #4's Quarterly MDS assessment, dated 11/25/2025, revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #4's care plan, initiated 04/11/2016, and revised 10/04/2025, revealed Resident #4 required assistance with all ADLs and mobility tasks. Interventions included 1. Resident #4 was bedbound and 2. Assist Resident #4 to turn and reposition every 2 hours and as needed. Resident #4's care plan, initiated 04/11/2014, and revised 10/04/2025, revealed Resident #4 was dependent on an indwelling Foley catheter due to Neuromuscular Dysfunction of the Bladder, Urinary Retention (a condition in which the bladder did not empty completely, leading to difficulty in urination), and Obstructive Uropathy. Interventions included 1. Check Resident #4 at routine intervals to assess needs and offer assistance with toileting, and 2. Resident #4 was dependent for toileting tasks. Resident #4 was also care planned on 04/11/2016, and revised 10/04/2025, for behavioral symptoms of making false allegation and threats toward staff, with interventions to include when Resident became inappropriate, disruptive, accusatory, or threatening, provide for basic needs, assess for pain, hunger, toileting needs, and temperature needs (too hot or too cold). Record review of Resident #4's progress note, dated 10/26/2025, revealed Resident #4 made an allegation of verbal abuse from a CNA, and family, the Administrator, the DON, and the Nurse Practitioner were made aware of the incident, and the incident was reported to state. Record review of Resident #4's active physician orders, started 12/13/2023, revealed an order for transportation to appointments may be set up via stretcher due to morbid obesity, Foley catheter, and Resident #4 was unable to stand or bear weight for transfers to the bed or wheelchair due to Paraplegia (a form of paralysis which specifically affects the legs and lower part of the body, often resulting from a problem with the nervous system). In an interview on 12/02/2025 at 10:35 AM, Resident #4 stated she did not feel like it was an appropriate thing for CNA-C make the statement we know what you like. She found it offensive, and she did not feel like it was meant like she knew what type of care she wanted or liked, but they felt like she wanted them to keep wiping or touching her private area. She stated she told CNA-C that it was inappropriate and uncalled for to talk to her like that, and she would provide the video of CNA-C during the incident on 10/25/2025. Observation of a video footage, dated 10/25/2025 9:43 PM, provided by Resident #4, CNA-C was cleaning Resident #4 while the MA assisted with handing her supplies, and CNA-C stated, Is it clean now? Resident #4 responded with yes, thank you. CNA-C stated Good. Yeah, we know what you like. Resident #4 responded Excuse me, that's not called for. CNA-C proceeded to raise her voice and stated No. No. No, it's not. You got us scrubbing down here when I already told you that I had already cleaned you, and I did. I had already cleaned you like 3 or 4 times already. That don't make any sense. In an interview on 12/02/2025 at 11:02 AM, the SW stated she thought she had spoken to the resident after the verbal abuse incident, but she could not recall for sure, and she did not think she had written a note regarding the incident. She stated the incident had occurred over the weekend, so she did not find out about it until the following Monday, and she usually went and spoke with residents after incidents or allegations, but she could not remember if she had spoken to Resident #4 in regard this incident. The SW also stated she was not sure if what CNA-C stated was considered verbal abuse because she had not known the context in which it was used or the surrounding conversation in which it happened. She stated she saw the video of the incident, but it was only a small section which did not show what led up to the incident or after the incident, so she was not sure if CNA-C saying oh, that's the way you like it, or we know how you like it was considered verbal abuse because it was all about interpretation. The SW stated she felt like CNA-C meant she knew how Resident #4 liked to be cleaned. In an interview on 12/02/2025 at 1:30 PM, CNA-C stated she knew she should not have said what she said, and she felt bad about it. CNA-C stated she gave Resident #4 good care, and she thought they had a good relationship where they joked, but it was not okay for Resident #4 to moan and groan or tell her to get in there deeper every time she wiped her vaginal area. CNA-C stated she had not even known what a labia was until Resident #4 told her to clean her labia good. CNA-C stated Resident #4 even referred to it as her bull's eye, and to clean her bull's eye good. She stated she was made to write her statement again because the Administrator did not feel her first statement was appropriate because she wrote what actually happened, and she was made to re-write her statement so it looked like she was referring to having known what type of care the resident liked instead of the fact Resident #4 liked the CNAs to keep wiping her vagina. CNA-C reiterated she knew what she said was wrong, but she should not have to keep wiping or cleaning Resident #4 just because she wanted her to, especially when she had already told Resident #4 she was already clean. CNA-C stated sometimes her mouth got her in trouble, but she was a good CNA, and she should not be forced to clean residents in a way which seemed or felt inappropriate. It was not okay. In an interview on 12/02/2025 at 2:06 PM, the MA stated CNA-C asked her to go with her to clean up Resident #4 because the staff preferred to have two people in Resident #4's room for peri-care. The MA stated CNA-C had cleaned front and back with soap, and had gotten Resident #4 clean, but Resident #4 told CNA-C to open her up and go deeper to clean her, and CNA-C then made the comment we know how you like it, meaning we knew how you liked for us to clean you. The MA stated Resident #4 made grunting sounds when she was wiped, but the MA never realized Resident #4 was meaning it in a sexual way, until Resident #4 told CNA-C to open her up and go harder and clean her labia and clean her deeper. The MA stated since the incident, she refused to go into the room to assist with Resident #4. In an interview on 12/02/2025 at 2:19 PM, ADON-A stated the MA called her and reported the incident and notified her Resident #4's family was at the facility and upset about the incident which had just happened. ADON-A stated she came to the facility and sent CNA-C home on suspension pending investigation, which ultimately ended in termination. ADON-A stated she spoke with Resident #4's family and watched the video, and determined it was inappropriate for CNA-C to say these things to Resident #4. She stated they followed protocol and reported everything like they were supposed to. In an interview on 12/03/2025 at 11:15 AM, the Administrator stated he knew staff were being interviewed about being made to re-write their statements during incidents or investigations, and he stated he would never do this, and the only time had staff re-write a statement was if something was misspelled, or if the statement written was not in regard to the incident the facility was investigating. The Administrator stated CNA-C was removed from Resident #4's hall during the investigation, then ultimately terminated. In an interview on 12/03/2025 at 4:23 PM, the DON stated CNA-C was a good CNA, but she should not have said what she said. The DON stated she did not feel CNA-C meant it the way Resident #4 took it because they joked around a lot together, and CNA-C was just joking with her, but still, it was not an appropriate thing to say to a resident. She stated CNA-C was terminated, and an Abuse and Neglect in-service was done with the staff. Record review of CNA-C's personnel file, dated 11/05/2025, revealed CNA-C was terminated, and her last day of work was on 10/29/2025. Record review of the facility's Abuse Prevention Policy, no date indicated, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident, consistent with resident rights, to include measurable objectives and timeframes to meet resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plans. The facility failed to develop or implement Resident #3's comprehensive care plan when, after searching for over 3 hours, they were unable to find Resident #3's comprehensive care plan in her chart, on the electronic medical system, or in medical records. This failure could place residents at risk of receiving inadequate care and services.The findings included: Record review of Resident #3's face sheet dated 09/17/2025 revealed an [AGE] year-old female with an admission date of 12/18/2024. Pertinent diagnoses included Unspecified Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain), Aphasia (a communication disorder which affects a person's ability to process and formulate language, and it could impact various aspects of communication, including speaking, understanding, reading, and writing), and Atrioventricular (AV) block (a condition characterized by the partial or complete block of electrical impulses from the atria (upper chambers) to the ventricles (lower chambers) of the heart. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed no BIMS as the BIMS interview was not conducted due to Resident #3 was rarely or never understood. C0700 and C0800 revealed Resident #3 had short-term and long-term memory problems. C1000 revealed severely impaired decision-making skills. C1310 revealed Resident #3 continuously had difficulty with focusing attention. GG0130 revealed Resident #3 was dependent with oral hygiene, toileting, showering, and personal hygiene. There was no care plan to be reviewed in the electronic chart or the paper chart. In an interview on 12/02/2025 at 4:45 PM, the SW stated she kept a list of quarterly care plan meetings due, and she was the one who sent out the notifications for the care plan meetings. The SW stated she was not sure whose responsibility it was to update the care plan information since they no longer had an MDS nurse, and she was not sure if Resident #3's care plan was ever completed. In an interview on 12/02/2025 at 4:55 PM, ADON-A stated the MDS nurse was the one who updated the care plans, but since they did not currently have an MDS nurse, the regional MDS nurses had been coming to help with care plans. ADON-A stated she was not sure how may care plans had been updated so far, but she knew they had been working on them. In an interview on 12/03/2025 at 4:14 PM, the DON stated care plan meeting should be held quarterly and with significant changes to update any changes or needs the resident may have had. She also stated the ADONs, and the Nurse Managers were the ones who should be updating the care plans since they did not currently have an MDS nurse. The DON stated she was not sure what happened to Resident #3's care plan. In an interview on 12/03/2025 at 4:35 PM, ADON-A stated care plan meetings were held quarterly and with significant changes, or at least they were supposed to be. The SW kept up with who needed the care plan meetings, and she sent out the notifications for the meetings. ADON-A stated after three hours searching for Resident #3's care plan, they were not able to find one. She was not sure if a care plan meeting was ever held or a comprehensive care plan was ever completed for Resident #3. She stated residents were supposed to have care plans to help staff identify the type of individualized care the residents needed. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, no date indicated, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, and the change of condition assessments to reflect the current conditions for 2 of 5 residents (Resident #1 and Resident #2) whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #1's care plan was revised after a significant change to accurately reflect current diagnoses and needs. The facility failed to ensure Resident #2's care plan had been reviewed or revised since 2024. These failures could place residents at risk of receiving inadequate, individualized care and services. The findings included: Record review of Resident #1's face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Pertinent diagnoses included Unspecified Dementia (a group of thinking and social symptoms which interfere with daily functioning) and Chronic Obstructive Pulmonary Disease (COPD, an ongoing lung condition caused by damage to the lungs). Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderately impaired cognition. The MDS assessment section J1400 revealed Resident #1 did not have a condition or chronic disease which resulted in a life expectancy of less than 6 months. The MDS assessment section N0415 revealed Resident #1 was not on an Opioid. The MDS assessment section O0110 revealed Resident #1 was placed on hospice care. Section Z0500 of the MDS assessment revealed it was signed as complete on 11/07/2025. Record review of Resident #1's active physician orders started 10/15/2025 revealed multiple orders for Morphine (an opioid, narcotic medication used to treat pain) for mild, moderate, or severe pain. There was another order dated for 10/15/2025 to admit Resident #1 to nursing home care under hospice routine care. Record review of Resident #1's comprehensive care plan, initiated 05/01/2025 and revised 07/03/2025, revealed the care plan had not been reviewed or revised since 07/03/2025. There was no care plan regarding Resident #1's hospice transition, and no care plan regarding Resident #1's morphine. Record review of an email dated 12/02/2025 at 4:35 PM, revealed the Administrator stated we (the facility) did our best to have care plan meetings, and the SW contacts hospice to attend, but they did not always comply. Record review of Resident #2's face sheet dated 12/03/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. Pertinent diagnoses included Unspecified Dementia (a group of thinking and social symptoms which interfere with daily functioning) and Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar (glucose), leading to high blood sugar levels and various health complications). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated moderately impaired cognition. The MDS assessment also revealed Resident #2 had lower extremity functional limitations. The quarterly MDS also revealed Resident #2 had active diagnoses of Coronary Artery Disease (CAD, a common type of heart disease which affects the main blood vessels which supply blood to the heart, called the coronary arteries), Hypertension (high blood pressure happens when the force of the blood pushing against the artery walls was consistently too high, and the heart had to work harder to pump blood), Unspecified Dementia (a group of thinking and social symptoms which interfere with daily functioning), Anxiety (intense, excessive and persistent worry and fear about everyday situations), and Depression (a mood disorder which causes a persistent feeling of sadness and loss of interest). The MDS was signed as completed by the DON on 09/11/2025. Record review of Resident #2's physician orders, started 03/02/2025, revealed an order for Amlodipine (a Hypertension medication). Record review of Resident #2's comprehensive care plan, revealed the care plan had not been reviewed, revised, or edited since 10/04/2024. The most recent MDS revealed a diagnosis of Hypertension, and the most recent physician orders revealed a hypertension, or high blood pressure, medication, but there was no care plan noted for the Hypertension or the medication. In an interview on 12/02/2025 at 4:45 PM, the SW stated she kept a list of quarterly care plan meetings which were due, and she was the one who sent out the notifications for the care plan meetings. The SW also stated she showed Resident #1 had a quarterly care plan meeting in September 2025 and a change of condition care plan meeting in October 2025, but she could not find the care conference meeting forms, and she was not sure whose responsibility it was to update the care plan information since they no longer had an MDS nurse. After stating she had Resident #1 on the care plan meeting lists for September 2025 and October 2025, SW then stated she could only find Resident #1 on the lists for care plan meetings for April 2025 and September 2025. The SW stated she could not find the care conference meeting forms, utilized in care plan meetings, to show that care plans had actually been held. In an interview on 12/02/2025 at 4:55 PM, ADON-A stated the MDS nurse was the one who was supposed to be updating the care plans, but they did not currently have an MDS nurse, so the Regional MDS nurses were the ones who had been coming to help with the care plans. She stated she was not sure if they had performed a care plan meeting or updated Resident #1's or Resident #2's care plans, but she was going to reach out to them and see what she could find out. After reaching out to them, she concluded neither care plan had been reviewed, revised or updated appropriately. In an interview on 12/03/2025 at 9:21 AM, the Regional MDS Nurse stated when she looked at Resident #2's care plan last night and updated it, it looked like it had been looked at it, but when she reviewed it, it had not been reviewed, revised, or updated. The Regional MDS Nurse stated there should have been a meeting for the quarterly care plans, as well as the care plans with a change of condition, and the care plans should have been reviewed and revised. The Regional MDS Nurse admitted prior to last night (12/02/2025) she had not looked at or updated Resident #1's or Resident #2's care plan. In an interview on 12/03/2025 at 4:14 PM, the DON stated care plans were used to identify the type of care residents need, and the ADONs and the MDS Nurse were responsible for checking to make sure the care plans were getting completed, but there currently was no MDS nurse. She stated the care plan meetings were supposed to be held quarterly and for significant changes, and if an MDS was completed for a significant change, a care plan meeting should have been held. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, no date indicated, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 11. The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS). 12. Assessments of the Residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for two of six residents (Resident #66 and Resident #93) reviewed for medication errors in that: 1) The facility failed to ensure Resident #66 was administered glargine insulin appropriately within parameters on 08/19/25 and 08/25/25. 2) The facility failed to ensure Resident #93 was administered glargine insulin appropriately by administering expired insulin on 09/16/25 and 09/17/25. These failures could place residents who receive insulin at an increased risk for complications such as hypoglycemia (low blood sugar), hyperglycemia (high blood sugar) and potential hospitalization.The findings included: 1) Record review of Resident #66's face sheet dated 09/17/25 revealed an [AGE] year-old male with an admission date of 10/09/24. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels). Record review of Resident #66's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 (severe impairment). Record review of Resident #66's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 04/16/25 and revised on 07/31/25. Approaches listed for the problem included .Administer Glucose Gel / Glucagon [as needed] as ordered initiated on 04/16/25. Record review of Resident #66's order summary revealed an active order for [Glargine] U-100 Insulin solution; 100 unit/mL; [amount]: 10 units; subcutaneous Special instructions: HOLD IF BLOOD SUGAR < 100 Once A Day initiated on 07/17/25. Record review of Resident #66's MAR revealed 10 units of glargine insulin were administered at 6:30 AM in Resident #66's right arm on 08/19/25 and left arm on 08/25/25. Further review revealed Resident #66's blood glucose was measured to be 92 on 08/19/25 and 86 on 08/25/25. Both records have an unknown nurse's initials by them. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated it was important to follow the doctor's orders and only administer medications when necessary. The DON stated administering medications outside of parameters, especially insulin, could lead to severe resident harm or even death. The DON stated the glargine insulin should not have been administered to Resident #66 when his glucose measured less than 100. 2) Record review of Resident #93's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/13/21. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels), and long-term use of insulin. Record review of Resident #93's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained due to the resident rarely being understood. Record review of Resident #93's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 10/21/22 and revised on 08/02/24. Approaches listed for the problem included .Administer routine [glargine] insulin as ordered. Administer [aspart insulin] for sliding scale as ordered. Administer [dulaglutide] as ordered initiated on 10/21/22. Record review of Resident #93's order summary revealed an active order for [Glargine] U-100 (insulin glargine) solution; 100 unit/mL; [amount]:5 UNITS; subcutaneous Once A Day initiated on 07/13/25. Record review of Resident #93's MAR revealed 5 units of glargine insulin were administered to Resident #93 at 9:00 AM on 09/16/25 and 09/17/25. During an observation of the 2300/2400 Halls medication cart at 2:00 PM on 09/17/25, this state surveyor found a glargine insulin pen with an open date of 08/18/25 and an expiration date of 09/15/25 in the top drawer. The label on the insulin pen revealed it was ordered for Resident #93. In an interview with RN F at 2:40 PM on 09/17/25, RN F stated she administered expired insulin glargine to Resident #93 on both 09/16/25 and 09/17/25. RN F stated she did not check to see if the insulin was expired before administering it to Resident #93. RN F stated insulin pens expired 28 days after opening them. RN F stated administering expired medications to residents could lead to unexpected side effects and ultimately harm the resident. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated it was dangerous to administer expired medications to residents. The DON stated nurses should check medications before administering them to ensure the medication, dose, route, expiration, and resident were all correct. The DON stated there should not have been expired insulin in the medication cart in the first place. The DON stated administering expired medications could lead to hyperglycemia or other unintended side effects. Record review of the undated facility policy titled Storage of Medications revealed the following policy: .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Record review of the undated facility policy titled Administering Medications revealed the following policy: .3. Medications must be administered in accordance with the orders, including any required time frame 7. The individual administering the medication shall follow the three rights of medication administration: right resident; right dose; right time 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #36, Resident #11, Resident #88, Resident #58) of 18 residents reviewed for care plans. The facility failed to develop and implement a comprehensive care plan for Resident #36, Resident #11, Resident #88, and Resident #58. This deficient practice could place residents at risk of not receiving services to meet their needs.The findings included: Review of Resident #36's face sheet revealed, the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia (group of symptoms affecting memory, thinking or language), Coronary Artery Disease (a type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen to the heart due to plaque buildup), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), Diabetes Mellitus (high blood sugars), and Depression (a persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed). Record review of Resident #36's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 09 which indicated his cognition was moderately intact. Review of Resident # 11's face sheet revealed, the resident was a [AGE] year-old male admitted to the facility on [DATE] with an original date of 12/21/2024. The resident had diagnoses which included Alzheimer's Disease (a progressive brain disorder that affects memory, thinking, and behavior), Coronary Artery Disease (a type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen to the heart due to plaque buildup), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), Depression (a persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed), and Muscle Wasting and Atrophy. Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 which indicated his cognition was severely impaired. A record review of Resident #88 Face sheet dated 09/17/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #88's diagnoses include Quadriplegia (A Paralysis that affects the ability to voluntarily move the upper and lower body), muscle atrophy (a condition that causes a progressive loss of muscle mass, strength, and power) Anxiety Disorder(a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and Depression(Is a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world. Resident #88's quarterly MDS 06/23/25 revealed a BIMS score of 14 which indicates normal thinking and memory with little to no impairment. Resident #88 Functional Abilities revealed Resident #88 is dependent on staff for all ADL's. Record review of Resident #58's admission record dated 09/10/25 revealed a [AGE] year-old male with diagnoses of Cerebral Infraction (when blood flow to brain is interrupted, causing damage to brain tissue), Unspecified, Hypertensive Heart Disease without Heart Failure (prolonged high blood pressure that damages the heart muscle), Essential (Primary) Hypertension (high blood pressure), Other Lack of Coordination, Need for Assistance with Personal Care, Muscle Wasting and Atrophy, not Elsewhere Classified, Multiple sites, and Anxiety Disorder Unspecified. Record Review of Resident #58's Quarterly MDS dated [DATE] reflected a BIMS Score of 8 indicating moderate impairment. In an interview on 09/18/2025 at 10:00 a.m. MDS LVN stated that she was the one responsible for completing the comprehensive care plans. She verified that there were no care plans for Resident #36 and Resident #11. MDS LVN stated that she must have overlooked their care plans. She stated that she started working from home as of July 2025 and does not have a set schedule to come in but tries to come at least once a week. She stated that the comprehensive care plans were to be completed within 21 days from the day that they were admitted . MDS LVN stated that the negative outcome of not having a comprehensive care plan was that there would be a lack of communication between the IDT team and staff not knowing in which direction they were going to provide care. In an interview on 09/18/2025 at 10:17 a.m., the DON stated that the comprehensive care plans were to be completed within 21 days from when the resident was admitted . She stated that the MDS LVN, corporate nurses, and the nurses were responsible for completing the comprehensive care plans. She stated that it was important for the comprehensive care plan to be completed for insurance purposes, to make sure that they got everything the patient needs and to know how to address it. In an interview on 09/18/2025 at 11:06 a.m., LVN Q stated that it had been about 2 weeks since she started working. She stated that the MDS nurse was responsible for completing the comprehensive care plan. She stated that she was responsible for completing the baseline care plan upon admission if she did the admission. LVN Q stated that if she were to complete a change of condition, then she would follow up with updating the care plan. She stated that she followed the care plan that was on file for that resident. LVN Q stated that the negative outcome of not having a comprehensive care plan was that someone can get hurt due to not updating interventions. In an interview on 09/18/2025 at 5:11 p.m. MDS LVN stated there was no care plan for Resident #58. She stated she was responsible for completing them and wasn't working at this facility full time and just overlooked it. In an interview on 09/18/25 at 6:03 PM with the MDS nurse she stated there was NO care plan for Resident #88. The state surveyor asked when the resident was admitted and the MDS nurse stated 11/13/24. The state surveyor asked why there was not care plan for Resident #88 and the MDS nurse stated she was not aware that a care plan had not been developed and implemented and did know why it was developed for this resident and would bring up to the DON so a care plan could be developed and implemented as soon as possible. Record review of the facility's Care Plans, Comprehensive [NAME]-Centered Policy, not dated, revealed Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. The facility failed to ensure items in the refrigerators and freezers were labeled and dated. The facility failed to ensure items stored in the dry storge room were correctly dated and labeled. The facility failed to ensure refilled cereal in cereal dispensers were dated and label with correct date. The facility failed to ensure gloves were used at all times while making preparing uncooked foods. The facility failed to ensure applesauce and pudding sitting out in room temperature were labeled with current date and time. These failures could place residents at risk of foodborne illnesses.The findings included: Observation and Initial tour of the kitchen on 09/16/25 at 8:15 A.M., revealed multiple gnats flying in the dish room and there was a foul odor. The sink drain was dripping liquid onto the floor. There was a block of cheese in the refrigerator unlabeled and undated. There was a tray of corn undated. In the dry goods storage room a bag of pasta had no label and undated. On one of the tables four cup sat at room temperature without dates, times, and legible labels. In observation on 09/17/24 at 5:10 PM for the return visit of the kitchen and interview revealed DA# N was going to make a sandwich for a resident and reached in and grabbed two slices of bread as she touched the first slice she realized she had no gloves threw away the bread and went and washed her hands again and put on gloves and started to make the sandwich. In an interview with DA O on 09/16/25 at 8:32 AM she said all kitchen staff were responsible for labeling any stored food in the refrigerator and cleaning the refrigerator and made sure that all food was labeled, had not expired and had a use by date. DA O stated the fridge was cleaned and all expired food was thrown out daily. DA O could not explain why the cheese and corn did not have a date of when they were placed in refrigerator. The dry goods storage room was cleaned out every time they received an order so at least once a week and a label with a received date and expiration date should be put on all items stored in the dry goods storage room. In an interview with the FSM on 09/16/25 at 9:43 AM stated she and the staff clean out the refrigerator daily and could not explain why the cheese had no label or date and why corn did not have a date only that it must have been done recently in error. The FSM stated she did not know why the pasta had no received by date or expiration date as all other items had a label with a date. The FSM said they could have been just used for cooking and label could have fallen off and could be the reason why the pasta had no labels with dates. The FSM stated she will do a retraining on the importance of dating food and making sure refrigerated food stored in refrigerator are dated, making sure dry food stored are all dated with received by and expiration dates, and throwing out expired foods for all forms of storage. In an interview on 09/17/25 at 5:16 PM with DA N said she was nervous because state surveyor was watching her make the sandwich a resident asked for during dinner time. DA#2 said she know not the touch any food she is going to prepare without washed and gloved hands. In an Interview on 09/17/25 at 5:30 PM with FSM she stated she would retain the staff on why and when to wash hands and put on gloves while serving and preparing food. Record review of the facility pest control receipts indicated gnats in the dish room was addressed and initialed by the MM and pest control technician on 04/22/25, 07/21/25 and 08/08/25. Record review of the facility kitchen policy titled, Sanitation and Infection Control-insect and rodent control revised 05/2016 revealed It is the policy of this home to prevent and control insect and rodent infestations within the dietary services department to prevent food borne illness. Under Procedure, 2. The home will maintain .properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. The sanitation of the kitchen will be maintained to prevent food sources, breeding places, etc. for insects or rodents. 8. The pest control company will leave a copy of treatments made in the kitchen at the end of each service call. Record review of the facility kitchen policy titled, Sanitation/Infection Control-Handwashing revised 06/2013 revealed Dietary employees are to wash hands to ensure sanitary work habits are established when handling or serving foods to residents. Procedure: 1. Employees are to wash hands: a. before starting work, b. between handling of dirty dishes and clean dishes, equipment/utensils, and food, c. after all work breaks, using restroom, tobacco use or eating, h. after touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces. 2. Hand washing occurs in sinks provided for that purpose .Food preparation sinks are not to be used for hand washing.References: U.S. Food and Drug Administration Food Code http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ :FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETYFOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of infection, for 2 of 5 Residents (Resident #40 and Resident #63) that were reviewed for infection control in that: 1. The facility failed to ensure the wound dressing on Resident #40 was dated and initialed. 2. The facility failed to ensure CNA I performed proper perineal care (incontinent care) with Foley catheter for Resident #63. These deficient practices could place residents in the facility at risk for infections, healthcare associated cross contamination, and the spread of infection.Findings included: 1.Record review of Resident #40's electronic face sheet, dated 09/18/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included: Unspecified Dementia, Cerebral Infarction (stroke), Aphasia (a language disorder that makes it hard to understand or express language), Heart Failure, Coronary Artery Disease (a type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen to the heart due to plaque buildup), Hypertension (high blood pressure), Anxiety, Depression, and Osteoarthritis (the protective cartilage in your joints breaks down). Record review of Resident #40's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 0, indicating her cognition was severely impaired. Resident #40's skin and injury treatments marked for application of nonsurgical dressings. Record review of Resident #40's person- centered care plan, initiated date 09/16/2025 reflected resident potential for injury: skin tears/bruising related to fragile skin, restless movements, bumping arms/legs, and ecchymotic skin (bruises). Interventions included treatment to skin ears per physician orders, geri-gloves or long sleeve clothes to protect arms, assess/monitor skin every shift, and handle carefully during transfers/repositioning. Record review of Resident #40's physician order reflected, left forearm skin tear: cleanse with normal saline, pat dry with 4x4 island gauze daily Monday, Wednesday, Friday, and as needed until resolved, dated 09/16/2025. During an observation on 09/16/2025 at 12:25 p.m. revealed Resident #40 was sitting in a wheelchair by the nurses' station upstairs. She had a wound dressing on her left forearm with no date and no initials. In an interview on 09/16/2025 at 12:27 p.m. RN F, the charge nurse for Resident #40, confirmed the resident had a wound dressing on her left forearm that was not labeled. She stated that she was not the one who applied the dressing. RN F stated that the nurse who applied it was responsible for labeling the dressing with the date and the initials. She stated that it was important to label the dressing to know when it needed to be changed. RN F stated that it was important to label the dressing because it can cause infection, not knowing how long they have had it for. She stated she had done wound training upon hire, which was about a month ago, but they have a wound care nurse. In an interview on 09/16/2025 at 3:39 p.m. with the WCN, stated that she did not put the dressing on Resident #40. She stated that it was important to label the dressings because then they would not know how long they have had it for, and it can cause infection. The WCN stated that the dressing should be labeled with the date and the nurse's initials upon application. She stated she had wound training last October and got her wound certification. She stated that she does get wound skill check offs. In an interview on 09/16/2025 at 6:45 p.m. with the DON, stated that the wound dressings were to be labeled with the date and the initials of the nurse to know when it was done. She stated that it was important for the nurse to ensure that it was labeled so they knew when to change it. The DON stated that by not having the dressing labeled the site can develop an infection or it can cause the infection to get worse. She stated that she had seen Resident #40's dressing on the left forearm not labeled the morning of, 09/16/2025, but she did not have a chance to notify the wound care nurse because the state surveyors walked in shortly after and she got busy. The DON stated that the WCN was new and that they hired another treatment nurse to assist. She stated that wound care training was done annually and as needed. She stated skill check offs are done as well. 2.Record review of Resident #63's electronic face sheet, dated 09/18/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and original date 02/20/2020. The resident had diagnoses which included: Neuromuscular Dysfunction of bladder (affects the nerves that control voluntary muscles of the bladder), Cerebral Infarction (stroke), Hemiplegia and Hemiparesis, Coronary Artery Disease (a type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen to the heart due to plaque buildup), Hypertension (high blood pressure), Anxiety, Depression, and Type 2 Diabetes Mellitus (high blood sugar). Record review of Resident #63's Quarterly MDS assessment, dated 06/26/2025 reflected a BIMS score of 11, indicating Resident #63 was moderately cognitively impaired. Resident #63 had an indwelling catheter and was always bowel incontinent. Record review of Resident #63's comprehensive person-centered care plan dated 08/18/2025 reflected Problem Resident #63 has indwelling Foley catheter due to Neuromuscular Dysfunction/Neuropathic Bladder. She is incontinent with uninhibited bowl. Interventions: Resident #63 Provide incontinent care promptly when found wet or soiled and resident is dependent for toileting tasks/incontinent care. During an observation on 09/17/2025 at 1:47 p.m. revealed CNA I cleansed Resident #63 bilateral groin folds. She then cleansed the left outer side of the labia with one swipe, disregarded wipe. She then proceeded to clean the catheter tubing. She did not clean the right outer side of the labia or both inner sides of the labia before she got to the catheter tubing. In an interview on 09/17/2025 at 2:06 p.m. CNA I, stated that she forgot to clean both outer and inner folds of the vaginal opening. She stated she got nervous, but she tried her best. CNA I stated that it was important to cleanse perineal area properly to prevent infection. She stated that in-services for infection control were done about once a month. In services for perineal care were done frequently with the most recent one done about a month ago. In an interview on 09/17/2025 at 2:10 p.m. ADON A, was present during the perineal care observation. She stated that she had seen that CNA I had not cleaned Resident #63 properly. She stated that she cleaned only one side of her labia fold. ADON A stated that Resident #63 was to be cleaned on both sides of the outer and inner labia before cleaning the foley catheter tube. She stated that CNA I was probably nervous. She stated that they have in-services for infection control and perineal care on a monthly basis. She stated that they do conduct perineal care skill check offs upon hire and annually. ADON A stated that it was important for the CNAs to do perineal care properly to prevent infection. In an interview on 09/18/2025 at 10:17 a.m. with the DON, she stated CNAs have competency checks for incontinent care done annually and as needed. She stated that the CNAs should have cleansed both sides of the inner and outer labia folds before proceeding to the foley catheter tubing. The DON stated this was important to provide proper perineal care for infection control. She stated the last in-service for infection control was done a couple days ago. Record review of the facility's skill check off record provided revealed WCN met requirements for Skin/Wound on 07/28/2025. Record review of the facility's skill check off record provided revealed CNA I met requirements for Perineal/Incontinent Care-Female on 06/11/2025. Record review of the facility's mandatory in-service dated 09/15/2025 revealed one of the topics discussed was Infection Control to include techniques for prevention and control of infections, Handwashing. Record review of the facility's Wound Care, Procedure policy, not dated, revealed Documentation:.The following information should be recorded in the resident's medical record, treatment sheet or designate wound form: 1. The date and time the dressing was changed. Record review of the facility's Incontinent Care/Perineal Care with or without a Catheter policy, revised date 07/2012, revealed Policy: It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination. Female:Wash clean to dirty Clean the middle outSpread labia and clean left, right, and center (clean to dirty; front to back)Pat dryWash inner thighs .Record review of the facility's Infection Prevention and Control Program Policy date revised December 2016 revealed: Policy Statement: 1.The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2.The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen tubing was changed and documented every night shift on Sunday as ordered. This failure could place residents at an increased risk of infection leading to a decline in health.The findings included: Record review of Resident #47's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/05/24. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (group of diseases that cause chronic inflammation and narrowing of the airways, making it difficult to breathe), and dependence on supplemental oxygen. Record review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15 (cognition intact). Further review revealed Resident #47 had not received oxygen within 14 days of the assessment. Record review of Resident #47's comprehensive care plan dated 09/17/25 revealed the problem Resident is at risk for respiratory distress [related to] chronic hypoxia (low oxygen)/COPD. Oxygen dependent initiated on 04/24/24 and revised on 08/06/24. Approaches listed for the problem included:Administer oxygen at 2-3 LPM via NC. Observe oxygen precautions revised on 08/06/24.Provide medications as ordered. Explain medication regimen, actions, and side effects revised on 08/06/24. Record review of Resident #47's order summary revealed an active order for Change updraft tubing, and humidifier bottle once a day on Sun[day] nights initiated on 04/05/24. Further review revealed an active order for Oxygen via NC at 2-5 Lpm to maintain saturation above 90% every shift initiated on 04/05/25. Record review of Resident #47's MAR revealed the last time staff documented Resident #47's oxygen tubing was changed was on 08/24/25. During an observation of Resident #47's room at 10:22 AM on 09/16/25, Resident #47 was resting in bed. Oxygen tubing attached to the oxygen concentrator was dated 4/27. In an interview with RN E at 10:24 AM on 09/16/25, RN E stated Resident #47's oxygen tubing was not dated correctly. RN E stated based on the date written on the oxygen tubing, she was unable to tell the last time it was changed. RN E stated the oxygen tubing was supposed to be changed out weekly to help prevent possible infections. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated the oxygen tubing was supposed to be changed out weekly on Sundays as ordered by the physician. The DON stated the oxygen tubing should be dated whenever it was changed out. The DON stated it was important to change out the oxygen tubing weekly to help prevent infection.Record review of the undated facility policy Oxygen Administration revealed the following policy: .10. Label oxygen tubing with date and initials and change per facility standard.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 4 medication carts (2300/2400 Cart) reviewed for storage. The facility failed to ensure the medication cart for halls 2300/2400 was free from expired insulin pens. The failure could place residents in the facility at risk of receiving expired medications from staff. The findings included: Record review of Resident #93's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/13/21. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels), and long-term use of insulin. Record review of Resident #93's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained due to the resident rarely being understood. Record review of Resident #93's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 10/21/22 and revised on 08/02/24. Approaches listed for the problem included .Administer routine [glargine] insulin as ordered. Administer [aspart insulin] for sliding scale as ordered. Administer [dulaglutide] as ordered initiated on 10/21/22. Record review of Resident #93's order summary revealed an active order for [Glargine] U-100 (insulin glargine) solution; 100 unit/mL; [amount]:5 UNITS; subcutaneous Once A Day initiated on 07/13/25. Record review of Resident #93's MAR revealed 5 units of glargine insulin were administered to Resident #93 at 9:00 AM on 09/16/25 and 09/17/25. During an observation of the 2300/2400 Halls medication cart at 2:00 PM on 09/17/25, this state surveyor found a glargine insulin pen with an open date of 08/18/25 and an expiration date of 09/15/25 in the top drawer. The label on the insulin pen revealed it was ordered for Resident #93. In an interview with RN F at 2:40 PM on 09/17/25, RN F stated she was in charge of the medication cart for halls 2300/2400 when the expired insulin pen was found. RN F stated insulin pens expired 28 days after taking them out of the refrigerator. RN F stated she did not have a good reason for why the expired insulin pen was still in the medication cart. RN F stated it was important to not keep expired medications in the medication cart, so they did not accidentally get administered to residents. RN F stated administering expired medications to residents may harm them in unexpected ways. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated expired medications should not be stored in the medication carts. The DON stated expired medications should be taken out of the carts and disposed of properly. The DON stated leaving expired medications in the medication carts may lead to a staff member inadvertently administering expired medications to a resident, potentially harming them. Record review of the undated facility policy Storage of Medications revealed the following policy: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #66) reviewed for accuracy and completeness of clinical records. The facility failed to accurately document the glucagon injection (hormone produced by the pancreas that raises blood sugar levels by signaling the liver to release stored glucose) Resident #66 received at approximately 7:45 AM on 07/08/25 in the MAR. This failure could result in residents' records not accurately reflecting the administration of medications and could result in further errors due to inappropriately administering medications twice. The findings included: Record review of Resident #66's face sheet dated 09/17/25 revealed an [AGE] year-old male with an admission date of 10/09/24. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels). Record review of Resident #66's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 (severe impairment). Record review of Resident #66's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 04/16/25 and revised on 07/31/25. Approaches listed for the problem included .Administer Glucose Gel / Glucagon [as needed] as ordered initiated on 04/16/25. Record review of Resident #66's order summary revealed an active order for Glucagon (HCl) Emergency Kit [reconstituted solution]; 1 mg; [amount] 1 MG; injection Special Instructions: GIVEN FOR HYPOGLYCEMIA (low blood sugar) Every 2 Hours - [as needed] initiated on 10/15/24. Record review of nurse's progress notes revealed a note written by LVN J at 7:45 AM on 07/08/25 that stated Resident #66's blood sugar was measured at 29 and the resident received a glucagon injection. The Resident's blood sugar was measured again at 8:15 AM and it had risen to 85. Record review of Resident #66's MAR revealed the order for Glucagon HCl was never administered during the month of July 2025. A phone interview was attempted with LVN J at 4:01 PM on 09/16/25, but LVN J did not return the phone call. In an interview with RN E at 10:24 AM on 09/16/25, RN E stated anytime a medication was administered it should be documented in the MAR. RN E stated it was important to document all medication administrations so another nurse did not come after and administer the same medication again. RN E stated it was also important to document all as needed medications to notice if there were any trends or patterns so they could make adjustments as needed. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated it was dangerous to administer medications and then not document them. The DON stated if it was not documented then another nurse may come afterwards and unnecessarily administer the same medication. The DON stated if a resident received double the dose of their medication it could become toxic for the resident, causing harm. Record review of the undated facility policy titled Administering Medications revealed the following policy: .16. The individual administering the medication must initial the resident's MAR on the appropriate line or EHR after giving each medication and before administering the next ones.

Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #5) of 6 residents reviewed for reporting. The DON did not report an allegation of verbal abuse made by Resident #5 on or about 08/24/25 to the Administrator, the ombudsman, or the state licensing/certification responsible for surveying/licensing the facility per facility policy. This failure could place residents at risk for physical, mental, and/or psychosocial harm.The findings included: Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #5's quarterly MDS dated [DATE] reflected in section C- Cognitive Patterns, a BIMS score of 15 which indicated she was cognitively intact. Section GG- Functional Abilities-Interim reflected Resident #5 was dependent (helper did all the effort, resident did none of the effort, to complete the activity) with toileting hygiene, shower/bathe self, and lower body dressing. Resident #5 required substantial/maximal assistance (helper did more than half the effort) to roll left and right in bed. Section H- Bladder and Bowel reflected Resident #5 had an indwelling urinary catheter, she was always incontinent of bowel, and a bladder and/or bowel toileting program were not being used. Record review of the facility's grievance dated 08/24/25 reflected the following: Resident Name: [Resident #5]Describe the grievance/concern: Resident complain that [LVN D] was rude to her and mistreat her. [sic]Expectation of person voicing concern: Spoke to [Resident #5] and [LVN D] will be transferred upstairs.Findings: Nurse will not work on [Resident #5's hall]- She will be transferred upstairs.Action Taken: [blank]Reportable to outside agency: NoIf yes, was this reported: [NAME] Whom: [DON]Date: [check mark]Investigation findings reported to person voicing concern: [neither yes nor no checked]How? In personNote: [Resident #5] is very selective as to who take care of her- She does not want the 2 nurses that worked here, that is [LVN G] and [LVN D] both LVN charge nurse. [sic]Person Completing Inquiry: [DON] signatureDate: 08/25/25 In an interview on 09/18/25 at 10:00 AM, Resident #5 stated she kept a logbook and had a log entry on 08/23/25 at 1:50 AM that stated LVN D barged in her room without knocking to see what CNA H was doing. Resident #5 stated it was the second time that shift LVN D did not knock before entering her room; it had also happened at 8:50 PM. Resident #5 stated, When [LVN D] did it the first time, we had words over knocking on the door because she [LVN D] walked in without knocking to tend to my roommate. [LVN D] stated that I was not going to do to her like I did to the other nurse about knocking. That she was not going to play that game. Resident #5 stated she complained to the DON on 08/24/25 about LVN D's behavior throughout the shift and showed her the video. Resident #5 then showed the surveyor a video dated 08/24/25. In that video, CNA H was performing incontinent care for Resident #5. Resident #5 can be heard telling LVN D to leave her room multiple times. LVN D stated to Resident #5 in a rude tone, No, I am not going to leave until I am done talking. I am the charge nurse. LVN D was also heard telling the CNA she was not going to take more than 15 minutes for care. In an interview on 09/18/25 at 12:28 PM, ADON A stated Resident #5 complained about LVN D a couple of weeks back. ADON A stated the CNAs took a long time with Resident #5 when care was provided because Resident #5 was very particular about the care and was also very picky about who provided care for her. ADON A stated that evening they had to get the CNA from the other side to take care of Resident #5, and LVN D went in the room and told the CNA she only had 15 minutes to do care for her (Resident #5) while CNA H was providing care. Resident #5 had told LVN D to leave the room and she left the room. LVN D got moved upstairs because she was PRN, and we needed her upstairs. LVN D got fired for that incident on 09/15/25 after we watched the video because of how she talked to Resident #5. ADON A stated in-services on abuse and neglect were done anytime there was an incident and monthly on the 15th of every month or the nearest weekday if the 15th was on a weekend. ADON A stated they went over the types of abuse and asked the staff to identify the different types of abuse. ADON A stated there were not any hand-outs that went with the abuse/neglect in-services, but staff was verbally quizzed about different scenarios, and they were to identify what type of abuse it was. In an interview on 09/18/25 at 12:51 PM, the SW stated Resident #5 had talked to her about LVN D being rude about the CNA taking too long to care for her approximately 1 1/2 to 2 weeks ago. The SW stated, I think she had talked to the DON before she talked to me. I don't know what was done about it, you'd have to ask the DON. The SW stated abuse/neglect in-services were on the agenda for the meetings that were held on the 15th of every month. The SW asked Resident #5 if she wanted to talk to psychiatric services and the following day, Resident #5 stated she did want to talk to them. In an interview on 09/18/25 at 1:01 PM, the DON stated, [Resident #5] has gotten to the point that she doesn't want anyone to care for her. I have 2 nurses and 2 aides on 3-11 that she won't let care for her. The same with day shift. I have asked the ombudsman for help, and she said she didn't have any suggestions. The DON stated Resident #5 took about 45 minutes to change her because she was very particular about what she wanted done and how it was done and when she wanted it done. The DON stated, [Resident #5] always threatens that she has video and will report us. The DON stated Resident #5 complained about LVN D approximately 2 weeks ago and said that LVN D was rude and unprofessional. The DON stated Resident #5 showed her the video a couple of weeks ago, and further stated, I was surprised with [LVN D] being so rude and disrespectful. The DON stated she and ADON A called LVN D into the office the next day and told her that she was unprofessional and asked her why she talked to [Resident #5] like that. The DON stated LVN D said she was tired of doing that all day and Resident #5 was very aggressive and would be on the call light all day long. The DON stated, We talked to [Resident #5] and told her that [LVN D] was not going to work that area anymore. The DON stated LVN D worked one shift after that, and she told them not to let her work anymore. The DON stated, We let her go on 09/15/25 for being disrespectful, rude, and unprofessional. You don't treat a patient like that. When asked if she thought LVN D's behavior was abuse, the DON stated, I would say that it was verbal abuse. I told the admin about it the same day that I did the interview with [Resident #5], about 2 weeks ago. Me, the ADON and the admin discussed it and decided it would be better to let the nurse go. The DON stated allegations of abuse were to be reported to the state within 2 hours, but this one was not reported within 2 hours because, We could not get a hold of her (LVN D). The DON stated when she talked to LVN D about it a couple of weeks ago, she (LVN D) said she was not coming back, but she did work another shift after that. The DON stated she told the ADONs not to have her come back in. Later in the interview the DON stated, It did not get reported to state because we were discussing it and listening to the video trying to decide if it was abuse or not, but we had already let her go. In an interview on 09/18/25 at 5:18 PM, the admin stated he found out about the issue between Resident #5 and LVN D when the ombudsman told him on Monday, 09/15/25. The Admin stated, the SW and I went over to talk to Resident #5, and she showed me a video where LVN D is telling the CNA H that she shouldn't be taking 45 minutes to change the resident. [Resident #5] was telling [LVN D] to get out of the room and [LVN D] kept talking to the CNA instead of leaving. I decided to report it to state even thought I hadn't even completed my investigation yet. When I listened to it, then I looked over the rules and regulations, I wanted to make sure that it would fall under verbal abuse. The more I looked at the video, I don't think she (LVN D) was trying to threaten her (Resident #5) or make her feel afraid, and [Resident #5] said she wasn't afraid of her, but I couldn't find anything that made me feel like it was abuse. The Admin stated that being rude and ugly toward someone did make it reportable and they let her go because they did not want her to be rude or ugly to anyone else. The Admin stated no one told him anything prior to 09/15/25. The Admin stated, For the most part, he did see the grievances. The Admin stated in the mornings he would ask the SW if there were any issues. He further stated he would ask for grievances at every morning meeting. The Admin stated he was surprised to know that there was a grievance about this issues before he heard it from the ombudsman. The Admin stated, If the DON had told me about that grievance, I would have reported it. Once I find out about abuse it's 2 hours to report, everything else is 24 hours. Once I saw the video, I reported it. The DON saw the video first and she came back and told me she was not sure if it was abuse or not, so then I went in with the SW and watched it, talked with corporate, then decided to report it. The Admin stated they had abuse/neglect in-services every month on the 15th. Record review of the facility's self-report dated 09/15/25 reflected in part:The facility was notified of the incident on 09/15/25 by the ombudsman.The facility's investigation summary stated, On the above date and time, the alleged victim advised that an LVN [LVD D] had spoken lo her very badly. Upon viewing the video of the incident, it showed that the LVN was telling the C.N.A., while in [Resident #5's] room, that she should not be taking 45 min. to clean her. [Resident #5] then became upset and started yelling for the LVN to get out. The LVN then staled to [Resident #5] that she was the charge nurse and that she would get out when she was finished talking to the C.N.A. Facility in-serviced staff on facility abuse and neglect policy. Responsible party, physician, police department and THHS were all notified of the incident. The facility's investigative findings were, Inconclusive. Provider Action Taken Post-Investigation: In-service staff on facility abuse and neglect. Subsequently alleged perp. was terminated.Record review of the facility's undated Abuse Investigation and Reporting policy reflected in part: Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting:1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. the local/State Ombudsman2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orb. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.5. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.Record review of the facility's undated Abuse Prevention policy reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.CORRECTIVE ACTION:Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.

Based on observation, record review and interview, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #86) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #86 with fingernail grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections. The findings included: Record review of Resident #86's Resident Face Sheet dated 09/18/25 reflected a [AGE] year-old male with an admission date of 09/27/24. Resident #87 had diagnoses which included Dementia (decline in brain functions such as, memory, thinking, problem-solving & language) in other diseases classified elsewhere, mild, with mood disturbance, Other lack of Coordination (difficulty with voluntary movements & balance), Need for assistance with personal care, Type 2 diabetes mellitus (chronic condition where body does not produce enough insulin to regulate blood sugar levels) with diabetic neuropathy (complication of diabetes that damages the nerves, leading to various symptoms and health problems), unspecified, Essential (primary)hypertension (persistent elevated blood pressure without an identifiable underlying cause) and Depression (feeling of sadness, that affects how you think, feel & act, making daily activities difficult), unspecified. Record review of Resident #86's quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment. For Functional abilities resident had impairment on both sides of upper extremity (shoulder, elbow, wrist, hand), and Personal hygiene Resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity). Observation and interview on 09/17/25 at 4:12 p.m. revealed Resident #86's nails untrimmed. Nails were observed to be about 2 centimeters in length from the tip of finger, also squared off at the tip of the nail. Resident #86's stated someone had come in about 2 weeks ago and asked him if he wanted them trimmed and he said at the time he was asleep and said no. He said he wanted them trimmed but no one has trimmed them or offered to do so. He said he had requested it. In an interview on 09/17/25 at 5:02pm LVN I said Resident #86 hadn't told him he wanted his fingernails trimmed. LVN I also said he hadn't asked him either. LVN I said no one had mentioned to him about trimming his fingernails. LVN I said only nurses could trim Resident #86's fingernails because he had a diagnosis of diabetes. He said they are inserviced often in the mornings on ADL's which included grooming. LVN I said if fingernails are not trimmed as needed, the resident could scratch himself or get an infection. In an interview on 09/18/25 at 3:38 p.m. CNA O said Resident # 86 usually doesn't like to have his nails cut. She said if he had told her, she would've let the nurse know because she can't cut his nails because he is diabetic. CNA O said they have received constant in-services on grooming residents. She said the last in-service she received was last week. In an interview on 09/18/25 at 4:09 p.m. LVN P said she had offered to trim Resident #86's fingernails about 2 weeks ago but he had declined. She said she had not asked him again. She said the nurses had to do his nail care due to him being a diabetic. LVN P said if his nails aren't trimmed, he could have cut himself or gotten an infection. She said they had received an in-service on grooming about a week ago. In an interview on 09/18/25 at 4:19 p.m. the DON stated the nurses were supposed to do nail grooming for diabetic residents. She said they should have asked residents if they wanted their nails trimmed. She said if resident nails were kept untrimmed it could have caused infections. Record Review of the facility's policy titled, Quality of Life - Dignity, updated on 02/2020 documented, Policy StatementEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and Implementation1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents reviewed for PASRR. (Resident #8). The facility failed to refer Resident #8 for PASRR Level II assessment when the facility had coded mental illness on his PASRR Level I assessment. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning. The findings included: Record review of Resident #8's Resident Face Sheet dated 09/18/25 reflected a [AGE] year-old male with a re-admission date of 09/04/24. Resident #8 had diagnoses which included Type 2 diabetes mellitus with other specified complication (body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), unspecified, Major Depressive disorder, recurrent (mental condition with repeated episodes of major depression), Post-traumatic stress disorder, unspecified (mental health condition that can develop after experiencing or witnessing a traumatic event), and Insomnia, unspecified (difficulty sleeping, staying asleep resulting in daytime tiredness & impaired functioning). Record review of Resident #8's quarterly MDS reflected a BIM score of 11 indicating moderate cognitive impairment. Record review of Resident #8's PASRR Level I Screening reflected in Section C questioning if there was evidence or an indicator that this individual had a Mental Illness to which the answer was Yes. Record review of Resident #8's medical chart reflected no evidence of Resident #8's PASRR Evaluation. Observation on 09/17/25 at 4:22 p.m. Resident #8 was observed in his room. Resident #8 had refused to speak with the Surveyor and didn't allow Surveyor to enter his room. During an interview on 09/18/25 at 4:50 p.m. MDS LVN said she wasn't able to find to find a PASRR Evaluation for Resident #8. She said she didn't know if one had been done for him. MDS LVN said she worked part time at the facility while they find someone to work fulltime. She said if resident didn't have the right assessments done they would miss out on opportunities for services like case management or programs to re-enter the community. During an interview on 09/18/25 at 6:25 p.m. the Admin said MDS oversees completing PASRR's. Record review of facility policy titled Resident Assessment Coordination of PASRR & Assessments dated 11/28/20 documented; ObjectiveTo provide the appropriate care and services needed for each resident admitted to the facility.PolicyReferring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #5) of 6 residents reviewed for abuse and neglect. The DON failed to follow the facility's policy to report an allegation of verbal abuse made by Resident #5 on or about 08/24/25 to the administrator, the ombudsman, or to the Texas Health and Human Services Commission (HHSC). This failure could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of timely reporting of incidents.The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #5's quarterly MDS dated [DATE] reflected in section C- Cognitive Patterns, a BIMS score of 15 which indicated she was cognitively intact. Section GG- Functional Abilities-Interim reflected Resident #5 was dependent (helper did all the effort, resident did none of the effort, to complete the activity) with toileting hygiene, shower/bathe self, and lower body dressing. Resident #5 required substantial/maximal assistance (helper did more than half the effort) to roll left and right in bed. Section H- Bladder and Bowel reflected Resident #5 had an indwelling urinary catheter, she was always incontinent of bowel, and a bladder and/or bowel toileting program were not being used.Record review of the facility's grievance dated 08/24/25 reflected the following: Resident Name: [Resident #5]Describe the grievance/concern: Resident complain that [LVN D] was rude to her and mistreat her. [sic]Expectation of person voicing concern: Spoke to [Resident #5] and [LVN D] will be transferred upstairs.Findings: Nurse will not work on [Resident #5's hall]- She will be transferred upstairs.Action Taken: [blank]Reportable to outside agency: NoIf yes, was this reported: [NAME] Whom: [DON]Date: [check mark]Investigation findings reported to person voicing concern: [neither yes nor no checked]How? In personNote: [Resident #5] is very selective as to who take care of her- She does not want the 2 nurses that worked here, that is [LVN G] and [LVN D] both LVN charge nurse. [sic]Person Completing Inquiry: [DON] signatureDate: 08/25/25In an interview on 09/18/25 at 10:00 AM, Resident #5 stated she kept a logbook and had a log entry on 08/23/25 at 1:50 AM that stated LVN D barged in her room without knocking to see what CNA H was doing. Resident #5 stated it was the second time that shift LVN D did not knock before entering her room; it had also happened at 8:50 PM. Resident #5 stated, When [LVN D] did it the first time, we had words over knocking on the door because she [LVN D] walked in without knocking to tend to my roommate. [LVN D] stated that I was not going to do to her like I did to the other nurse about knocking. That she was not going to play that game. Resident #5 stated she complained to the DON on 08/24/25 about LVN D's behavior throughout the shift and showed her the video. Resident #5 then showed the surveyor a video dated 08/24/25. In that video, CNA H was performing incontinent care for Resident #5. Resident #5 can be heard telling LVN D to leave her room multiple times. LVN D stated to Resident #5 in a rude tone, No, I am not going to leave until I am done talking. I am the charge nurse. LVN D was also heard telling the CNA she was not going to take more than 15 minutes for care.In an interview on 09/18/25 at 12:28 PM, ADON A stated Resident #5 complained about LVN D a couple of weeks back. ADON A stated the CNAs took a long time with Resident #5 when care was provided because Resident #5 was very particular about the care and was also very picky about who provided care for her. ADON A stated that evening they had to get the CNA from the other side to take care of Resident #5, and LVN D went in the room and told the CNA she only had 15 minutes to do care for her (Resident #5) while CNA H was providing care. Resident #5 had told LVN D to leave the room and she left the room. LVN D got moved upstairs because she was PRN, and we needed her upstairs. LVN D got fired for that incident on 09/15/25 after we watched the video because of how she talked to Resident #5. ADON A stated in-services on abuse and neglect were done anytime there was an incident and monthly on the 15th of every month or the nearest weekday if the 15th was on a weekend. ADON A stated they went over the types of abuse and asked the staff to identify the different types of abuse. ADON A stated there were not any hand-outs that went with the abuse/neglect in-services, but staff was verbally quizzed about different scenarios, and they were to identify what type of abuse it was.In an interview on 09/18/25 at 12:51 PM, the SW stated Resident #5 had talked to her about LVN D being rude about the CNA taking too long to care for her approximately 1 1/2 to 2 weeks ago. The SW stated, I think she had talked to the DON before she talked to me. I don't know what was done about it, you'd have to ask the DON. The SW stated abuse/neglect in-services were on the agenda for the meetings that were held on the 15th of every month. The SW asked Resident #5 if she wanted to talk to psychiatric services and the following day, Resident #5 stated she did want to talk to them.In an interview on 09/18/25 at 1:01 PM, the DON stated Resident #5 complained about LVN D approximately 2 weeks ago and said that LVN D was rude and unprofessional. The DON stated Resident #5 showed her the video a couple of weeks ago, and further stated, I was surprised with [LVN D] being so rude and disrespectful. The DON stated she and ADON A called LVN D into the office the next day and told her that she was unprofessional and asked her why she talked to [Resident #5] like that. The DON stated LVN D said she was tired of doing that all day and Resident #5 was very aggressive and would be on the call light all day long. The DON stated, We talked to [Resident #5] and told her that [LVN D] was not going to work that area anymore. The DON stated LVN D worked one shift after that, and she told them not to let her work anymore. The DON stated, We let her go on 09/15/25 for being disrespectful, rude, and unprofessional. You don't treat a patient like that. When asked if she thought LVN D's behavior was abuse, the DON stated, I would say that it was verbal abuse. I told the Admin about it the same day that I did the interview with [Resident #5], about 2 weeks ago. Me, the ADON and the Admin discussed it and decided it would be better to let the nurse go. The DON stated allegations of abuse were to be reported to the state within 2 hours, but this one was not reported within 2 hours because, We could not get a hold of her (LVN D). The DON stated when she talked to LVN D about it a couple of weeks ago, she (LVN D) said she was not coming back, but she did work another shift after that. The DON stated she told the ADONs not to have her come back in. Later in the interview the DON stated, It did not get reported to state because we were discussing it and listening to the video trying to decide if it was abuse or not, but we had already let her go.In an interview on 09/18/25 at 5:18 PM, the Admin stated he found out about the issue between Resident #5 and LVN D when the ombudsman told him on Monday, 09/15/25. The Admin stated, the SW and I went over to talk to Resident #5, and she showed me a video where LVN D is telling the CNA H that she shouldn't be taking 45 minutes to change the resident. [Resident #5] was telling [LVN D] to get out of the room and [LVN D] kept talking to the CNA instead of leaving. I decided to report it to state even thought I hadn't even completed my investigation yet. When I listened to it, then I looked over the rules and regulations, I wanted to make sure that it would fall under verbal abuse. The more I looked at the video, I don't think she (LVN D) was trying to threaten her (Resident #5) or make her feel afraid, and [Resident #5] said she wasn't afraid of her, but I couldn't find anything that made me feel like it was abuse. The Admin stated that being rude and ugly toward someone did make it reportable and they let her go because they did not want her to be rude or ugly to anyone else. The Admin stated no one told him anything prior to 09/15/25. The Admin stated, For the most part, he did see the grievances. The Admin stated in the mornings he would ask the SW if there were any issues. He further stated he would ask for grievances at every morning meeting. The Admin stated he was surprised to know that there was a grievance about this issues before he heard it from the ombudsman. The Admin stated, If the DON had told me about that grievance, I would have reported it. Once I find out about abuse it's 2 hours to report, everything else is 24 hours. Once I saw the video, I reported it. The DON saw the video first and she came back and told me she was not sure if it was abuse or not, so then I went in with the SW and watched it, talked with corporate, then decided to report it. The Admin stated they had abuse/neglect in-services every month on the 15th.Record review of the facility's self-report dated 09/15/25 reflected in part:The facility was notified of the incident on 09/15/25 by the ombudsman.The facility's investigation summary stated, On the above date and time, the alleged victim advised that an LVN [LVD D] had spoken lo her very badly. Upon viewing the video of the incident, it showed that the LVN was telling the C.N.A., while in [Resident #5's] room, that she should not be taking 45 min. to clean her. [Resident #5] then became upset and started yelling for the LVN to get out. The LVN then staled to [Resident #5] that she was the charge nurse and that she would get out when she was finished talking to the C.N.A. Facility in-serviced staff on facility abuse and neglect policy. Responsible party, physician, police department and THHS were all notified of the incident. The facility's investigative findings were, Inconclusive. Provider Action Taken Post-Investigation: In-service staff on facility abuse and neglect. Subsequently alleged perp. was terminated. Record review of the facility's undated Abuse Prevention policy reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.CORRECTIVE ACTION:Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.Record review of the facility's undated Abuse Investigation and Reporting policy reflected in part: Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting:1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. the local/State Ombudsman2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orb. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.5. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 resident's bathroom sink (Resident # 43 and #88) and 2 of 5 resident rooms (Resident #76 and Resident #114) reviewed for the environment in that: The bathroom sinks in resident #43's and Resident #88's room were clogged. Resident #76's wall pad and floor mats were torn. Resident #76's nightstand was broken. Resident #114's bathroom sink cabinet door was missing. Resident #114's trim wall trim inside her bedroom was broken off. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortableA record review of Resident #43's Face Sheet 09/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #43's diagnoses included Multiple Sclerosis(is a chronic autoimmune disease that affects the central nervous system, leading to a range of neurological symptoms due to the immune system attacking the protective myelin sheath around nerve fibers), Muscle Atrophy (The loss or thinning of muscle mass, which can significantly impact strength and physical function), Depression (Is a mood disorder characterized by a persistent feeling of sadness and a loss of interest in activities once enjoyed), and Hypotension (A condition in which the force of the blood pushing against the artery walls is too low). A record review of Resident #43's MDS ([NAME] Data Set) dated 07/31/25 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicates normal thinking and memory with little to no impairment. Resident #43 Functional Abilities revealed Resident #43's performance indicated the resident is dependent on staff for all ADL's (Activities of Daily Living). A record review of resident #43's care plan dated 09/17/25 revealed resident requires assistance for ASL and mobility tasks due to generalized weakness and poor endurance. Potential for unavoidable decline due to same. The resident has reduced range of motion to bilateral lower extremities. A record review of Resident #88's Face sheet dated 09/17/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #88's diagnoses include Quadriplegia (A Paralysis that affects the ability to voluntarily move the upper and lower body), muscle atrophy (a condition that causes a progressive loss of muscle mass, strength, and power) Anxiety Disorder(a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and Depression (Is a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world). Resident #88's MDS 06/23/25 revealed a BIMS score of 14 which indicates normal thinking and memory with little to no impairment. Resident #88 Functional Abilities revealed Resident #88 is dependent on staff for all ADL's. Resident #88 Revealed no care was available for this resident as a baseline care plan was never created in the time frame allowed. Record review of Resident #76's face sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE] with most recent admission on [DATE]. Diagnoses included cerebral palsy (a group of conditions that affect movement and posture that is caused by damage that occurs to the developing brain, most often before birth), history of falling, seizure disorder (abnormal brain activity which affects muscle control, behavior, and awareness), unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), and aphasia (an impairment in the ability to read, write, and speak). Record review of Resident #76's comprehensive MDS dated [DATE] reflected in section C- Cognitive Patterns: Cognitive Skills for Daily Decision Making a score of 3 which indicated that Resident #76 had severely impaired cognitive skills and never/ rarely made decisions. Section GG- Functional Abilities-Interim reflected Resident #76 was dependent (helper does all of the effort, resident does none of the effort to complete activities) for all of his ADLs. Resident #76 was not able to roll side to side in bed, sit up, or transfer without extensive staff assistance. Section H- Bladder and Bowel reflected Resident #76 was always incontinent of bladder and bowel. Record review of Resident #76's care plan dated 03/05/20 reflected in part:Focus: Special Care- Resident has seizure disorder. Start date: 03/05/20. Goal: Resident will not injure himself due to seizure disorder with seizures prevented to extent possible through next review.Approaches: Concave mattress on floor with floor mat to be used as ordered and indicated. Start date: 11/23/22. Torso harness with seatbelt to be applied while up in wheelchair to assist with proper positioning and safety due to cerebral palsy and convulsions. Check every 1 hour and PRN, release and reposition resident every 2 hours for 10 minutes and PRN. Start date: 11/23/22. Focus: Falls- Potential for falls due to history of falls, weakness, impaired balance, seizure disorder, severe cognitive impairment/ safety awareness with intellectual disability/ mental retardation, cerebral palsy with spastic uncontrolled movements to all extremities and neuroleptic and psychotropic medication administration. Start date: 03/05/20. Goal: Reduce the risk for falls while preventing injury through next review date. Approaches: Concave mattress/ floor mattress to establish bed boundaries and reduce risk of rolling out of bed as ordered. Floor mat to be used as ordered. Start date: 11/23/22. Record review of Resident #114's Resident Face Sheet dated 09/17/25 reflected a [AGE] year-old female with a re-admission date of 08/08/25. Resident #114 had diagnoses which included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary Admission), Essential (primary) hypertension, Schizophrenia, unspecified. Record review of Resident #114's quarterly MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. The MDS also revealed Resident #114's Mobility devices included a walker and manual wheelchair. During an observation on 09/16/25 beginning at 10:48 AM Resident #76's bed was turned so that the head of the bed was toward the room entry door. The headboard of Resident #76's bed was against the wall that connected with the bathroom and the right side of the bed was against the right side wall. There was a grey pad screwed to the right side wall that had 12 horizontal tears ranging in length from less than 1/2 inch to over 18 inches in length and 6 vertical tears ranging in length from less than 1/2 inch to over 6 inches on it. The largest vertical tear was approximately 1/2 inch wide. Resident #76 had 2 floor mats beside his bed with one long continuous rip that started in approximately the middle of the first floor mat and extended through approximately 1/3 of the second floor mat. Resident #76's 2 drawer nightstand was missing the second/ bottom drawer, and the guide tracks were visible. The front piece of the missing drawer was leaned against the front/bottom of the nightstand, on the floor, with a trashcan against it. In observation and interview on 09/16/25 beginning at 11:13 AM of Resident #43's and Resident #88's bathroom, the sink was clogged halfway with dirty water. The state surveyor asked how long the sink had been clogged both residents said since earlier that morning could not honestly give an exact time. Resident #43 stated the clogging of the sink happened at least 4 times a month and maintenance will resolve the problem within the day it occurred. During an observation on 09/16/25 beginning at 3:35 PM Resident #114's restroom was observed to be missing a cabinet door underneath the sink exposing sink pipes underneath. Also observed in Resident #114's room was trim against wall that was broken off. In an interview on 09/16/25 at 3:52 PM, CNA R said she hadn't noticed the missing cabinet in Resident #114's restroom, she also said she hadn't paid attention to the trim on the walls. She stated they were supposed to report those things to maintenance so they can fix them. In an interview on 09/18/25 at 2:24 PM, ADON A stated everyone was responsible for setting up rooms. ADON A stated she did not know of any rules for how rooms were set up, but she was aware that beds were not supposed to be against the wall because it could prevent residents from getting out of bed. ADON A stated Resident #76's bed was against the wall because he had spastic movements and could fall out of the bed. There was also a pad on the wall so that he would not hurt himself if he hit the wall and a floor mat beside the bed. ADON A stated housekeeping was responsible for changing the pad on the wall, the floor mats, and the nightstand and she did not know how long the pad, mats or nightstand had been that way. In an interview on 09/18/25 at 2:35 PM, the MM stated maintenance was responsible for changing the pad on the wall in Resident #76's room and it was changed at the end of April 2025. The MM stated the floor mats were changed out as they needed to be, and the nightstands were replaced as they were reported. The MM stated it was the responsibility of whoever saw the issue to report it in the maintenance logbook or it was told to him directly. He stated no one has said anything about Resident #76's room lately. When shown what the pad on the wall, the floor mats, and the nightstand looked like, the MM stated he would go change them out now. The MM stated that would be the second wall pad that had been replaced. When asked if he knew of any regulations regarding how the room was set up and how beds were supposed to be arranged, the MM stated Life Safety told him beds had to be 18 inches away from the wall. Interview on 09/18/25 at 4:38 PM the Maintenance man stated resident rooms are being fixed starting with 200 hall and then the rest of the halls. The MM stated no time frame had been given but the maintenance crew was actively working on the project. The MM stated the staff was to report any issues of clogging sinks and toilets immediately. The MM stated no work order needs to be done it is a priority even if after hours. The MM stated if the problem is constantly happening after being monitored for some time a plumbing company would be called to come and service the room. The MM stated last week the plumbing company was called to a clogged toilet he could not fix themselves, but if a sink occurs the maintenance crew will try to fix the problem in house before the plumber would be called. The MM stated no residents are to try to unclog sinks or toilets themselves as all plungers are kept in the janitor's closet. In an interview on 09/18/2025 at 5:20 PM with the Administrator he stated anybody that sees the issue of plumbing should report the issue immediately. The admin stated if the plumber needs to be called if the issue cannot be resolved in house. The admin stated any plumbing issues will be taken care of As soon as possible and the maintenance man should be able to call the plumber to fix the problem without workorder or issues of cost. Record review of the facility's policy titled, Statement of resident rights, dated 07/20/20 revealed in part: Dignity and Respect: You have the right to: Live in safe, decent and clean conditions.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 residents personal refrigerators reviewed for food safety (Resident #114) in that: Resident #114's personal refrigerator located in her room was observed to have 2 slices of pie that were not dated or labeled. This failure could place residents at risk for food-borne illnesses.The findings included: Record review of Resident #114's Resident Face Sheet dated 09/17/25 reflected a [AGE] year-old female with a re-admission date of 08/08/25. Resident #114 had diagnoses which included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary Admission), Essential (primary) hypertension, Schizophrenia, unspecified. Record review of Resident #114's BIMS score quarterly MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. An observation on 09/16/25 at 3:40 p.m. of Resident #114's personal refrigerator revealed 2 slices of pie covered in plastic wrap and were not dated or labeled. In an interview on 09/16/25 at 3:42 p.m. the RP stated he had not brought in those pies and he didn't know when they were brought in. In an interview on 09/16/25 at 3:59 p.m. CNA R stated she doesn't check residents' refrigerators, she said the night nurses check them. She said they check them for temperature and dates. CNA R said she didn't check Resident #114's refrigerator and said she'd check it and remove any food not dated. In an interview on 09/16/25 at 3:59 p.m. LVN T said she checks residents' personal refrigerators. She said she checked the temperature but did not check the label or dates of food. She said she checks them every day on her shift. When asked why she didn't check the food dates or labels, she did not answer. Record review of the facility policy, titled Foods Brought by Family/Visitors not dated documented, Policy StatementFood brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #5) of 5 residents reviewed for resident rights. The facility failed to provide Resident #5 with choices concerning her caregivers for personal care. LVN D did not leave the room when Resident #5 asked her multiple times to step out on 08/23/25. LVN D did not treat Resident #5 with respect and dignity on 09/05/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle wasting and atrophy (loss of muscle mass and strength), morbid (severe) obesity due to excess calories (weight is more than 80 to 100 pounds above a person's ideal body weight) and neuropathy (damage to nerves outside of the brain and spinal cord that leads to pain, weakness, numbness or tingling in one or more parts of the body). Record review of Resident #5's quarterly MDS dated [DATE] reflected in section C- Cognitive Patterns, a BIMS score of 15 which indicated she was cognitively intact. Section GG- Functional Abilities-Interim reflected Resident #5 was dependent (helper did all the effort, resident did none of the effort, to complete the activity) with toileting hygiene, shower/bathe self, and lower body dressing. Resident #5 required substantial/maximal assistance (helper did more than half the effort) to roll left and right in bed. Section H- Bladder and Bowel reflected Resident #5 had an indwelling urinary catheter, she was always incontinent of bowel, and a bladder and/or bowel toileting program were not being used. Record review of Resident #5's care plan dated 04/11/16 reflected a problem of resident required assistance for all ADL and mobility tasks due to paraplegia, neuropathy, weakness, impaired balance, and poor endurance/ activity tolerance with start date 04/11/16. The goal was resident would be clean/ well-groomed/ appropriately dressed, would have mobility needs met, and would maintain current functional ability through review date. Approaches included resident required extensive X1 staff assistance for personal hygiene tasks, dressing, and clothing changes daily and PRN (start date 01/28/21). Resident #5's care plan also reflected a problem of resident had hx of making false allegations/threats towards staff members. Refused care from all staff at times, had preferences in staff she preferred, and stated staff refused to attend to her needs if staff she preferred were not on schedule, with start date 04/11/16 and edit date 09/30/24. The goal was resident would reduce the number of threatening remarks toward staff throughout next review. Approaches included convey an attitude of acceptance toward the resident, maintain a calm environment and approach to the resident, maintain a calm, understandable approach, repeat as necessary, set acceptable expectations and limits for resident and ensure resident that all needs have been met by staff every day, support appropriate moods/behavior, and when resident begins to become inappropriate, disruptive, accusatory, or threatening, provide for basic needs: assess for pain, hunger, toileting, too hot/cold, etc. dated 01/28/21. Resident #5's care plan further reflected a problem of resident had an electronic monitoring device in bedroom per their and family's wishes with start date 03/07/24. The goal was resident's and family's wishes were to be respected throughout next review (long term goal target date 10/31/24). In an interview on 09/16/25 at 11:12 AM and 09/18/25 at 10:00 AM, Resident #5 stated due to her childhood trauma she had a lot of issues and because of those issues, she would not allow men to change her. Resident #5 stated to her knowledge, all the CNAs were told when they started working at the facility that males would not perform incontinent care for her. Resident #5 stated there were 2 new CNAs that were orienting, and to her knowledge they were both female. Resident #5 stated she found out later that one of them (CNA C) was a male but was representing himself as a female. She stated he was very good at the job he was doing, and she had no complaints other than the fact that some staff knew he was not biologically a female but allowed him to provide incontinent care for her anyway. Resident #5 stated LVN G was taken off her care several years ago and she had not seen her in approximately 5 years. Resident #5 stated, Recently something possessed her, exactly what, I don't know. [LVN G] was upset because [CNA H] was coming to a different hall to change me. Resident #5 stated LVN G came to her door 3 times to rush CNA H and the resident reported her (LVN G). Resident #5 stated she felt like LVN G was getting back at her for complaining about her. Resident #5 stated, They had found out earlier in the week that [CNA C] was a male, but [LVN G] sent him in here anyway. Resident #5 states she was told by CNA H that LVN G stopped her from changing her (Resident #5) and instead sent CNA C to change her. Resident #5 stated CNA H was off for the weekend after that and when she came back CNA H told her she was so sorry, there was nothing she could do about it, but LVN G told CNA C to go change her (Resident #5) and to never tell her that he was not a female. Resident #5 stated, It made me so mad because of all the stuff I'd been through in my childhood. Over time here, I was able to let males help a little bit like adjust my diaper or zinc oxide ointment. But when I found out that the nurse sent him, knowing he was a male, I couldn't understand how a nurse could be so evil. Resident #5 stated she has had to take control of her anxiety and her emotions and talk to her church for emotional support because of LVN G. Resident #5 stated CNA C did not mistreat her in any way, but she felt that he should have been honest with her. Resident #5 stated they did talk to CNA C then he and his sister (also a CNA) both quit. Resident #5 stated she kept a logbook and had a log entry on 08/23/25 at 1:50 AM that stated LVN D barged in her room without knocking to see what CNA H was doing. Resident #5 stated it was the second time that shift LVN D did not knock before entering her room; it had also happened at 8:50 PM. Resident #5 stated, When [LVN D] did it the first time, we had words over knocking on the door because she [LVN D] walked in without knocking to tend to my roommate. [LVN D] stated that I was not going to do to her like I did to the other nurse about knocking. That she was not going to play that game. Resident #5 stated she complained to the DON on 08/24/25 about LVN D's behavior throughout the shift and showed her the video. Resident #5 then showed the surveyor a video dated 08/24/25. In that video, CNA H was performing incontinent care for Resident #5. Resident #5 asked LVN D to step out of the room. LVN D can be heard saying, She can be in here 15 minutes. Resident #5 told LVN D to step out of the room again. LVN replied, I will when I am done speaking to her. I'm the charge nurse. Resident #5 again told LVN D to step out of the room. LVN D stated, No, she will not be in here that long. She will not be in here 45 minutes. LVN D then left the room. In the 16 second video clip, Resident #5 can be heard telling LVN D to step out of the room [ROOM NUMBER] times total. Resident #5 showed the surveyor a video dated 09/05/25 at 10:09 PM. In that video which lasted 48 seconds, Resident #5 was on her left side and LVN D was seen placing a brief under her. Resident #5 asked, Clean it? and pointed to her buttocks area. LVN D replied, No, no, no. Just wait. Scoot over there. Resident #5 stated, You better clean me with soap. LVN D answered, No. No, You just wait 'til I get over there. I was wiping off all the poop first, as she was tucking the brief under Resident #5's hip. LVN D stated, Don't talk to me like that cause I won't do it. I won't come in here. That's for sure. I'm over here making sure that you have nothing on you first. That way we get nothing on the clean diaper, while she was using peri foam to wipe Resident #5 and the video ended. Resident #5 showed the surveyor a video dated 09/05/25 at 10:10 PM. In that video which lasted 1 minute and 46 seconds, LVN D was performing incontinent care for Resident #5 who was rolled to her left side. LVN D told Resident #5, OK, come back. Resident #5 asked her, Did you get the folds? LVN D then answered rudely, Unh-uh. Yes, I did. We had the foam. Yah. I'm not gonna sit there and toalla and toalla (towel and towel in Spanish). No. I do what I. And I used the foam, the peri wash on you and that's all I need to do. And put cream. And cleaned in between your creases. Resident #5 rolled to her back and stated, You need to put cream down here, right here where I got the rash, and pointed to the back of her upper thigh/buttocks area. LVN D said to her, No. No ma'am. Unh-uh. No. This is. I'm already doing this. And that's all I'm gonna do. I have cream, the [name of the ointment] ointment all over the place, while wiping cream on Resident #5's inner thigh. LVN D then handed the packet to the person in the room that was helping her and told Resident #5, OK, roll this way or however you do. Resident #5 rolled to her right side and asked, Am I dirty on that side? LVN D answered, No. I told you I cleaned you with a lot of them and we used the peri foam. Resident #5 asked, OK, you put cream over here on this side? LVN D answered, No, because I did it already. Resident #5 replied, Not on that side. LVN D told her, yes, I did [Resident #5]. Resident #5 rolled onto her back and LVN D stated, Now come on. Let's get this on and I'm going to empty the catheter before I leave. Resident #5 said, Now we gotta get this [unintelligible]. Don't pull it, don't pull it. (Referring to her urinary catheter). LVN D stated, Not right now. OK then, you need to lift up because I'm fixing to walk out. The video ended at that point. In a telephone interview on 09/17/25 at 4:29 PM, CNA C stated he worked at the facility for 2 weeks. He stated he quit, and it was the worst place he had ever worked. CNA C stated the facility was aware that he was a male because his ID showed he was a male, but the night nurses did not know he was a male since he looked like a female and had breasts. CNA C stated when he started, he was just put on the floor alone with no orientation, no teaching, no nothing. CNA C stated it was probably 3 days in, they figured out he was a boy because of a conversation that they had. CNA C stated he did not know it was an issue for him to provide care for Resident #5 until another nurse who, he guessed had been there longer, yelled at him to not go in there because that resident (Resident #5) was not to have care done by males. CNA C stated after that night, he went in her room to clean up and stuff, just not provide incontinent care or anything. CNA C stated Resident #5 did not have any issues with him going in to clean her room or anything, and never told him that she knew he was a boy. CNA C stated, On my last day, I asked [Resident #5] is everything ok because she just randomly asked me who the charge nurse was for this hall and the other hall. When I went to tell the nurse about the interaction, the nurse started yelling at me and calling me stupid for going in there. She was yelling at me that males could not go in there and provide care. That night, the nurses also wouldn't let me go upstairs to get a female CNA to provide care. And they would not go in and provide care. CNA C stated his last night was 9/2/25. CNA C stated, I saw that all of the nurses were rude to her on purpose. On my first day there, they were telling me that I would not want to care for her because she was needy about the way that we change her. Basically, she gets a bed bath every time we change her. You soap her up on the front, wipe it, re-soap it, wipe it, then do the same on the back. Changing her took about an hour. CNA C stated he originally talked to the DON and the HR person. During his interview, the DON asked what shift he wanted to work (he stated overnight), how long had he been a CNA, (he stated 3 months), and how much he wanted to be paid. She then said to come in on Wednesday (08/13/25). CNA C stated, The HR lady just gave me paperwork to fill out. They copied my ID which says I'm male. CNA C stated, After the nurse yelled at me, I was crying and [CNA H] walked with me and said she was sorry, that she did not know I was a boy. [CNA H] said she would have told me about [Resident #5] not wanting a male to provide care. CNA C further stated, The nurses knew before that night that I was a guy, but it was a few days before that they told me not to provide care. 2 days before my last day, I went up to have 2 female CNAs from upstairs switch with me to provide care for Resident #5, but the nurses said to ignore [Resident #5] because she did not want my help. [Resident #5] was on the call light so I told her that I would get someone to help her. An hour later her light was still on, and I asked her if anyone had gone to help her and she said no. I told her that I had told the nurses and that's when she asked me for their names, I told her I didn't know then described them and she told me she knew who they were. So that's when I went out and told the 300 hall nurse that [Resident #5] wanted to know her name. My nurse in the 200 hall is the one who told me to ignore her. She had just put in her 2 week notice that day. She was saying she was quitting because they were so short staffed. The nurses never moved from the nurse's station all night. In an interview on 09/18/25 at 11:44 AM, CNA L stated she had been at the facility for three years and normally worked in Resident #5's hall. She was able to name the abuse coordinator and the types of abuse. She stated if she saw any abuse she would report it right away to the charge nurse and to the Admin. CNA L stated new CNAs oriented on which residents were continent or incontinent, what the daily routine was, and they had a sheet at the nurse's station in the ADL book that listed residents with any special needs. CNA L stated there were special instructions regarding Resident #5's care, but she did not remember specifically what the instructions were. CNA L stated the last in-service over ANE was 09/15/25 and they were every month on the 15th. CNA L stated the in-service covered types of abuse, who to report it to, resident hydration and cleaning. CNA L was not sure what constituted abuse. CNA L stated, [Resident #5] just has her ways and if she did not like you, she would not let you touch her. CNA L stated she was not allowed to take care of Resident #5 because Resident #5 said she was being too rough with her. CNA L stated, [Resident #5] has certain people that she does want to take care of her and certain ones that she doesn't, but she did not remember the names of any of them. In an interview on 09/18/25 at 12:16 PM, CNA N stated she had been at the facility for over 10 years and primarily worked in Resident #5's hall. CNA N stated there were a lot of people that Resident #5 did not like and on the day shift, the only person she liked was CNA N. CNA N stated, If [Resident #5] did not like anyone that was working, she would wait the entire shift to be changed because she would not let anyone she did not like change her. With her it was always 2 people because she was always accusatory, so in the mornings, a nurse had to go with me sometimes if [Resident #5] didn't like any of the other CNAs. CNA N stated Resident #5 did not like men to provide care for her and only 1 male CNA could check to see if she needed to be changed, but he was not allowed to provide incontinent care. CNA A stated the male CNA could be in the room, but he had to face away. CNA N stated ANE in-service was done the 15th of every month, and the last one was 09/15/25. CNA N stated they gave papers with the in-service that went into more detail about the training. In an interview on 09/18/25 at 12:28 PM, ADON A stated Resident #5 complained about LVN D a couple of weeks back. ADON A stated the CNAs took a long time with Resident #5 when care was provided because Resident #5 was very particular about the care and was also very picky about who provided care for her. ADON A stated that evening they had to get the CNA from the other side to take care of Resident #5, and LVN D went in the room and told the CNA she only had 15 minutes to do care for her (Resident #5) while CNA H was providing care. Resident #5 had told LVN D to leave the room and she left the room. LVN D got moved upstairs because she was PRN, and we needed her upstairs. LVN D got fired for that incident on 09/15/25 after we watched the video because of how she talked to Resident #5. ADON A stated in-services on abuse and neglect were done anytime there was an incident and monthly on the 15th of every month or the nearest weekday if the 15th was on a weekend. ADON A stated they went over the types of abuse and asked the staff to identify the different types of abuse. ADON A stated there were not any hand-outs that went with the abuse/neglect in-services, but staff was verbally quizzed about different scenarios, and they were to identify what type of abuse it was. In an interview on 09/18/25 at 12:51 PM, the SW stated Resident #5 had talked to her about LVN D being rude about the CNA taking too long to care for her approximately 1 1/2 to 2 weeks ago. The SW stated, I think she had talked to the DON before she talked to me. I don't know what was done about it, you'd have to ask the DON. The SW stated abuse/neglect in-services were on the agenda for the meetings that were held on the 15th of every month. The SW stated Resident #5 was tying our hands because she would not allow many of the CNAs to provide care. The SW stated there was only one specific CNA downstairs that was allowed to take care of her that she knew of. The SW asked Resident #5 if she wanted to talk to psychiatric services and the following day, Resident #5 stated she did want to talk to them. In an interview on 09/18/25 at 1:01 PM, the DON stated, [Resident #5] has gotten to the point that she doesn't want anyone to care for her. I have 2 nurses and 2 aides on 3-11 that she won't let care for her. The same with day shift. I have asked the ombudsman for help, and she said she didn't have any suggestions. The DON stated Resident #5 took about 45 minutes to change her because she was very particular about what she wanted done and how it was done and when she wanted it done. The DON speculated maybe Resident #5 just wanted company, but they had so many residents that they could not spend an hour at a time in with Resident #5. The DON stated, [Resident #5] always threatens that she has video and will report us. The DON stated Resident #5 complained about LVN D approximately 2 weeks ago and said that LVN D was rude and unprofessional. The DON stated Resident #5 showed her the video a couple of weeks ago, and further stated, I was surprised with [LVN D] being so rude and disrespectful. The DON stated she and ADON A called LVN D into the office the next day and told her that she was unprofessional and asked her why she talked to [Resident #5] like that. The DON stated LVN D said she was tired of doing that all day and Resident #5 was very aggressive and would be on the call light all day long. The DON stated, We talked to [Resident #5] and told her that [LVN D] was not going to work that area anymore. The DON stated LVN D worked one shift after that, and she told them not to let her work anymore. The DON stated, We let her go on 09/15/25 for being disrespectful, rude, and unprofessional. You don't treat a patient like that. When asked if she thought LVN D's behavior was abuse, the DON stated, I would say that it was verbal abuse. I told the Admin about it the same day that I did the interview with [Resident #5], about 2 weeks ago. Me, the ADON and the Admin discussed it and decided it would be better to let the nurse go. The DON stated allegations of abuse were to be reported to the state within 2 hours, but this one was not reported within 2 hours because, We could not get a hold of her (LVN D). The DON stated when she talked to LVN D about it a couple of weeks ago, she (LVN D) said she was not coming back, but she did work another shift after that. The DON stated she told the ADONs not to have her come back in. Later in the interview the DON stated, It did not get reported to state because we were discussing it and listening to the video trying to decide if it was abuse or not, but we had already let her go. In an interview on 09/18/25 at 5:18 PM, the Admin stated he found out about the issue between Resident #5 and LVN D when the ombudsman told him on Monday, 09/15/25, and that he was out of the facility for part of the week between 08/24/25 and 08/30/25. The Admin stated, the SW and I went over to talk to Resident #5, and she showed me a video where LVN D is telling the CNA H that she shouldn't be taking 45 minutes to change the resident. [Resident #5] was telling [LVN D] to get out of the room and [LVN D] kept talking to the CNA instead of leaving. I decided to report it to state even thought I hadn't even completed my investigation yet. When I listened to it, then I looked over the rules and regulations, I wanted to make sure that it would fall under verbal abuse. The more I looked at the video, I don't think she (LVN D) was trying to threaten her (Resident #5) or make her feel afraid, and [Resident #5] said she wasn't afraid of her, but I couldn't find anything that made me feel like it was abuse. The Admin stated that being rude and ugly toward someone did make it reportable and they let her go because they did not want her to be rude or ugly to anyone else. The Admin stated no one told him anything prior to 09/15/25. The Admin stated, For the most part, he did see the grievances. The Admin stated in the mornings he would ask the SW if there were any issues. He further stated he would ask for grievances at every morning meeting. The Admin stated he was surprised to know that there was a grievance about this issues before he heard it from the ombudsman. The Admin stated, If the DON had told me about that grievance, I would have reported it. Once I find out about abuse it's 2 hours to report, everything else is 24 hours. Once I saw the video, I reported it. The DON saw the video first and she came back and told me she was not sure if it was abuse or not, so then I went in with the SW and watched it, talked with corporate, then decided to report it. The Admin stated they had abuse/neglect in-services every month on the 15th. Record review of the facility's grievance dated 08/21/25 at 10:06 AM reflected the following: Resident Name: [Resident #5]Describe the grievance/concern: Resident complain on a CNA that whoever did peri care-had done a very good job-but she did not know weather it was a he or a she- & was very concerned [sic].Expectation of person voicing concern: Resident voiced that she does not want the 2 CNA that work her hall [sic].Findings: Resident also complain on my 2 nurses that work 7P to 7A [sic].Action taken: Spoke to [LVN G] and advise her to please, do not go to her room- never again- because resident hates her. Also on the other nurse, Resident says she does not knock at her room. 8/22/25 Advice to other nurse- to please knoce at her door- this is a state regulation & she must follow up- she agreed. *Note 2 of my CNA & (1) nurse are not allowed to go to her room. Because she resident does not want them [sic].Reportable to outside agency? NoIf yes, was this reported? NoInvestigation findings reported to person voicing concerns? YesHow? In personNote: On the complain above I have an older CNA that will attend her (unreadable name) Now when [CNA H] is off, one of the CNA upstairs will help her [sic].Person Completing Inquiry: [DON] signatureDate: 08/23/25Record Review of the facility's Quality of Life-Dignity Policy dated 02/2020 reflected in part: Policy StatementEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and Implementation1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.6. Residents' private space and property shall be respected at all times.a. Staff will knock and request permission before entering residents' rooms.7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:b. Promptly responding to the resident's request for toileting assistance.Record review of the facility's undated admission packet reflected in part: Statement of Resident RightsYou, the resident, do not give up rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights.If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER].Dignity and RespectYou have the right to:Be free from abuse, neglect, and exploitation.Be treated with dignity, courtesy, consideration, and respect and be free from discrimination based on age, race, religion, sex, nationality, disability, marital status, or source of payment.Freedom of choice:You have the right to:Make your own choices regarding personal affairs, care, benefits, and services.Participation in your care:You have the right to:Receive all care necessary to have the highest possible level of health.Participate in developing a plan of care, to refuse treatment, and to refuse to participate in experimental research.Complaints:You have the right to:Complain about care or treatment and receive a prompt response to resolve the complaint without fear of reprisal or discrimination.Your rights may be restricted only to the extent necessary to protect you or others, or to protect the rights of others, particularly those rights relating to privacy and confidentiality. These described rights are in add remedies an individual may be entitled to, according to rules under law.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse, neglect, misappropriations of resident property, and exploitation for 1 (Resident #5) of 5 residents reviewed for abuse. LVN D was verbally abusive to Resident #5 on two occasions on 08/24/25 and 09/05/25. This failure could place residents at risk for physical, mental, and/or psychosocial harm. The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle wasting and atrophy (loss of muscle mass and strength), morbid (severe) obesity due to excess calories (weight is more than 80 to 100 pounds above a person's ideal body weight) and neuropathy (damage to nerves outside of the brain and spinal cord that leads to pain, weakness, numbness or tingling in one or more parts of the body). Record review of Resident #5's quarterly MDS dated [DATE] reflected in section C- Cognitive Patterns, a BIMS score of 15 which indicated she was cognitively intact. Section GG- Functional Abilities-Interim reflected Resident #5 was dependent (helper did all the effort, resident did none of the effort, to complete the activity) with toileting hygiene, shower/bathe self, and lower body dressing. Resident #5 required substantial/maximal assistance (helper did more than half the effort) to roll left and right in bed. Section H- Bladder and Bowel reflected Resident #5 had an indwelling urinary catheter, she was always incontinent of bowel, and a bladder and/or bowel toileting program were not being used. Record review of Resident #5's care plan dated 04/11/16 reflected a problem of resident required assistance for all ADL and mobility tasks due to paraplegia, neuropathy, weakness, impaired balance, and poor endurance/ activity tolerance with start date 04/11/16. The goal was resident would be clean/ well-groomed/ appropriately dressed, would have mobility needs met, and would maintain current functional ability through review date. Approaches included resident required extensive X1 staff assistance for personal hygiene tasks, dressing, and clothing changes daily and PRN (start date 01/28/21). Resident #5's care plan also reflected a problem of resident had hx of making false allegations/threats towards staff members. Refused care from all staff at times, had preferences in staff she preferred, and stated staff refused to attend to her needs if staff she preferred were not on schedule, with start date 04/11/16 and edit date 09/30/24. The goal was resident would reduce the number of threatening remarks toward staff throughout next review. Approaches included convey an attitude of acceptance toward the resident, maintain a calm environment and approach to the resident, maintain a calm, understandable approach, repeat as necessary, set acceptable expectations and limits for resident and ensure resident that all needs have been met by staff every day, support appropriate moods/behavior, and when resident begins to become inappropriate, disruptive, accusatory, or threatening, provide for basic needs: assess for pain, hunger, toileting, too hot/cold, etc. dated 01/28/21. Resident #5's care plan further reflected a problem of resident had an electronic monitoring device in bedroom per their and family's wishes with start date 03/07/24. The goal was resident's and family's wishes were to be respected throughout next review (long term goal target date 10/31/24). Record review of the facility's grievance dated 08/24/25 reflected the following: Resident Name: [Resident #5]Describe the grievance/concern: Resident complain that [LVN D] was rude to her and mistreat her. [sic]Expectation of person voicing concern: Spoke to [Resident #5] and [LVN D] will be transferred upstairs.Findings: Nurse will not work on [Resident #5's hall]- She will be transferred upstairs.Action Taken: [blank]Reportable to outside agency: NoIf yes, was this reported: [NAME] Whom: [DON]Date: [check mark]Investigation findings reported to person voicing concern: [neither yes nor no checked]How? In personNote: [Resident #5] is very selective as to who take care of her- She does not want the 2 nurses that worked here, that is [LVN G] and [LVN D] both LVN charge nurse. [sic]Person Completing Inquiry: [DON] signatureDate: 08/25/25 In an interview on 09/18/25 at 10:00 AM, Resident #5 stated she kept a logbook and had a log entry on 08/23/25 at 1:50 AM that stated LVN D barged in her room without knocking to see what CNA H was doing. Resident #5 stated it was the second time that shift LVN D did not knock before entering her room; it had also happened at 8:50 PM. Resident #5 stated, When [LVN D] did it the first time, we had words over knocking on the door because she [LVN D] walked in without knocking to tend to my roommate. [LVN D] stated that I was not going to do to her like I did to the other nurse about knocking. That she was not going to play that game. Resident #5 stated she complained to the DON on 08/24/25 about LVN D's behavior throughout the shift and showed her the video. Resident #5 then showed the surveyor a video dated 08/24/25. In that video, CNA H was performing incontinent care for Resident #5. Resident #5 asked LVN D to step out of the room. LVN D can be heard saying, She can be in here 15 minutes. Resident #5 told LVN D to step out of the room again. LVN replied, I will when I am done speaking to her. I'm the charge nurse. Resident #5 again told LVN D to step out of the room. LVN D stated in a rude tone, No, she will not be in here that long. She will not be in here 45 minutes. LVN D then left the room. In the 16 second video clip, Resident #5 was heard telling LVN D to step out of the room [ROOM NUMBER] times total. Resident #5 showed the surveyor a video dated 09/05/25 at 10:09 PM. In that video which lasted 48 seconds, Resident #5 was on her left side and LVN D was seen placing a brief under her. Resident #5 asked, Clean it? and pointed to her buttocks area. LVN D replied, No, no, no. Just wait. Scoot over there. Resident #5 stated, You better clean me with soap. LVN D answered, No. No, You just wait 'til I get over there. I was wiping off all the poop first, as she was tucking the brief under Resident #5's hip. LVN D stated, Don't talk to me like that cause I won't do it. I won't come in here. That's for sure. I'm over here making sure that you have nothing on you first. That way we get nothing on the clean diaper, while she was using peri foam to wipe Resident #5 and the video ended. Resident #5 showed the surveyor a video dated 09/05/25 at 10:10 PM. In that video which lasted 1 minute and 46 seconds, LVN D was performing incontinent care for Resident #5 who was rolled to her left side. LVN D told Resident #5, OK, come back. Resident #5 asked her, Did you get the folds? LVN D then answered rudely, Nuh-uh. Yes, I did. We had the foam. Yah. I'm not gonna sit there and toalla and toalla (towel and towel in Spanish). No. I do what I. And I used the foam, the peri wash on you and that's all I need to do. And put cream. And cleaned in between your creases. Resident #5 rolled to her back and stated, You need to put cream down here, right here where I got the rash, and pointed to the back of her upper thigh/buttocks area. LVN D said to her, No. No ma'am. Nuh-uh. No. This is. I'm already doing this. And that's all I'm gonna do. I have cream, the [name of the ointment] ointment all over the place, while wiping cream on Resident #5's inner thigh. LVN D then handed the packet to the person in the room that was helping her and told Resident #5, OK, roll this way or however you do. Resident #5 rolled to her right side and asked, Am I dirty on that side? LVN D answered, No. I told you I cleaned you with a lot of them and we used the peri foam. Resident #5 asked, OK, you put cream over here on this side? LVN D answered, No, because I did it already. Resident #5 replied, Not on that side. LVN D told her, yes, I did [Resident #5]. Resident #5 rolled onto her back and LVN D stated, Now come on. Let's get this on and I'm going to empty the catheter before I leave. Resident #5 said, Now we gotta get this [unintelligible]. Don't pull it, don't pull it. (Referring to her urinary catheter). LVN D stated, Not right now. OK then, you need to lift up because I'm fixing to walk out. The video ended at that point. n a telephone interview on 09/17/25 at 4:29 PM, CNA C stated he worked at the facility for 2 weeks. He stated he quit, and it was the worst place he had ever worked. CNA C stated when he started, he was just put on the floor alone with no orientation, no teaching, no nothing. CNA C stated it was probably 3 days in, they figured out he was a boy because of a conversation that they had. CNA C stated he had provided incontinent care for Resident #5 a few times and he did not know it was an issue for him to provide care for Resident #5 until another nurse who, he guessed had been there longer, yelled at him to not go in there because that resident (Resident #5) was not to have care done by males. CNA C stated after that night, he went in her room to clean up and stuff, just not provide incontinent care or anything. CNA C stated Resident #5 did not have any issues with him going in to clean her room or anything, and never told him that she knew he was a boy. CNA C stated, On my last day, I asked [Resident #5] is everything ok because she just randomly asked me who the charge nurse was for this hall and the other hall. When I went to tell the nurse about the interaction, the nurse started yelling at me and calling me stupid for going in there. She was yelling at me that males could not go in there and provide care. That night, the nurses also wouldn't let me go upstairs to get a female CNA to provide care. And they would not go in and provide care. CNA C stated his last night was 9/2/25. CNA C stated, I saw that all of the nurses were rude to her on purpose. On my first day there, they were telling me that I would not want to care for her because she was needy about the way that we change her. Basically, she gets a bed bath every time we change her. You soap her up on the front, wipe it, re-soap it, wipe it, then do the same on the back. Changing her took about an hour. CNA C stated he originally interviewed with the DON and then met with the HR person a couple of days later. During his interview, the DON asked what shift he wanted to work (he stated overnight), how long had he been a CNA, (he stated 3 months), and how much he wanted to be paid. She then told him to come in on Wednesday (08/13/25). CNA C stated, The HR lady just gave me paperwork to fill out. They copied my ID which says I'm male. CNA C stated, After the nurse yelled at me, I was crying and [CNA H] walked with me and said she was sorry, that she did not know I was a boy. [CNA H] said she would have told me about [Resident #5] not wanting a male to provide care. CNA C further stated, The nurses knew before that night that I was a guy, but it was a few days before that they told me not to provide care. 2 days before my last day, I went up to have 2 female CNAs from upstairs switch with me to provide care for Resident #5, but the nurses said to ignore [Resident #5] because she did not want my help. [Resident #5] was on the call light so I told her that I would get someone to help her. An hour later her light was still on, and I asked her if anyone had gone to help her and she said no. I told her that I had told the nurses and that's when she asked me for their names, I told her I didn't know then described them and she told me she knew who they were. So that's when I went out and told the 300 hall nurse that [Resident #5] wanted to know her name. My nurse in the 200 hall is the one who told me to ignore her. She had just put in her 2 week notice that day. She was saying she was quitting because they were so short staffed. The nurses never moved from the nurse's station all night. In an interview on 09/18/25 at 11:44 AM, CNA L stated she had been at the facility for three years and normally worked in Resident #5's hall. She was able to name the abuse coordinator and the types of abuse. She stated if she saw any abuse she would report it right away to the charge nurse and to the Admin. CNA L stated new CNAs oriented on which residents were continent or incontinent, what the daily routine was, and they had a sheet at the nurse's station in the ADL book that listed residents with any special needs. CNA L stated there were special instructions regarding Resident #5's care, but she did not remember specifically what the instructions were. CNA L stated the last in-service over ANE was 09/15/25 and they were every month on the 15th. CNA L stated the in-service covered types of abuse, who to report it to, resident hydration and cleaning. CNA L was not sure what constituted abuse. CNA L stated, [Resident #5] just has her ways and if she did not like you, she would not let you touch her. CNA L stated she was not allowed to take care of Resident #5 because Resident #5 said she was being too rough with her. CNA L stated, [Resident #5] has certain people that she does want to take care of her and certain ones that she doesn't, but she did not remember the names of any of them. In an interview on 09/18/25 at 12:16 PM, CNA N stated she had been at the facility for over 10 years and primarily worked in Resident #5's hall. CNA N stated there were a lot of people that Resident #5 did not like and on the day shift, the only person she liked was CNA N. CNA N stated, If [Resident #5] did not like anyone that was working, she would wait the entire shift to be changed because she would not let anyone she did not like change her. With her it was always 2 people because she was always accusatory, so in the mornings, a nurse had to go with me sometimes if [Resident #5] didn't like any of the other CNAs. CNA N stated Resident #5 did not like men to provide care for her and only 1 male CNA could check to see if she needed to be changed, but he was not allowed to provide incontinent care. CNA A stated the male CNA could be in the room, but he had to face away. CNA N stated ANE in-service was done the 15th of every month, and the last one was 09/15/25. CNA N stated they gave papers with the in-service that went into more detail about the training. In an interview on 09/18/25 at 12:28 PM, ADON A stated Resident #5 complained about LVN D a couple of weeks back. ADON A stated the CNAs took a long time with Resident #5 when care was provided because Resident #5 was very particular about the care and was also very picky about who provided care for her. ADON A stated that evening they had to get the CNA from the other side to take care of Resident #5, and LVN D went in the room and told the CNA she only had 15 minutes to do care for her (Resident #5) while CNA H was providing care. Resident #5 had told LVN D to leave the room and she left the room. LVN D got moved upstairs because she was PRN, and we needed her upstairs. LVN D got fired for that incident on 09/15/25 after we watched the video because of how she talked to Resident #5. ADON A stated in-services on abuse and neglect were done anytime there was an incident and monthly on the 15th of every month or the nearest weekday if the 15th was on a weekend. ADON A stated they went over the types of abuse and asked the staff to identify the different types of abuse. ADON A stated there were not any hand-outs that went with the abuse/neglect in-services, but staff was verbally quizzed about different scenarios, and they were to identify what type of abuse it was. In an interview on 09/18/25 at 12:51 PM, the SW stated Resident #5 had talked to her about LVN D being rude about the CNA taking too long to care for her approximately 1 1/2 to 2 weeks ago. The SW stated, I think she had talked to the DON before she talked to me. I don't know what was done about it, you'd have to ask the DON. The SW stated abuse/neglect in-services were on the agenda for the meetings that were held on the 15th of every month. The SW stated Resident #5 was tying our hands because she would not allow many of the CNAs to provide care. The SW stated there was only one specific CNA downstairs that was allowed to take care of her that she knew of. The SW asked Resident #5 if she wanted to talk to psychiatric services and the following day, Resident #5 stated she did want to talk to them. In an interview on 09/18/25 at 1:01 PM, the DON stated, [Resident #5] has gotten to the point that she doesn't want anyone to care for her. I have 2 nurses and 2 aides on 3-11 that she won't let care for her. The same with day shift. I have asked the ombudsman for help, and she said she didn't have any suggestions. The DON stated Resident #5 took about 45 minutes to change her because she was very particular about what she wanted done and how it was done and when she wanted it done. The DON speculated maybe Resident #5 just wanted company, but they had so many residents that they could not spend an hour at a time in with Resident #5. The DON stated, [Resident #5] always threatens that she has video and will report us. The DON stated Resident #5 complained about LVN D approximately 2 weeks ago and said that LVN D was rude and unprofessional. The DON stated Resident #5 showed her the video a couple of weeks ago, and further stated, I was surprised with [LVN D] being so rude and disrespectful. The DON stated she and ADON A called LVN D into the office the next day and told her that she was unprofessional and asked her why she talked to [Resident #5] like that. The DON stated LVN D said she was tired of doing that all day and Resident #5 was very aggressive and would be on the call light all day long. The DON stated, We talked to [Resident #5] and told her that [LVN D] was not going to work that area anymore. The DON stated LVN D worked one shift after that, and she told them not to let her work anymore. The DON stated, We let her go on 09/15/25 for being disrespectful, rude, and unprofessional. You don't treat a patient like that. When asked if she thought LVN D's behavior was abuse, the DON stated, I would say that it was verbal abuse. I told the Admin about it the same day that I did the interview with [Resident #5], about 2 weeks ago. Me, the ADON and the Admin discussed it and decided it would be better to let the nurse go. The DON stated allegations of abuse were to be reported to the state within 2 hours, but this one was not reported within 2 hours because, We could not get a hold of her (LVN D). The DON stated when she talked to LVN D about it a couple of weeks ago, she (LVN D) said she was not coming back, but she did work another shift after that. The DON stated she told the ADONs not to have her come back in. Later in the interview the DON stated, It did not get reported to state because we were discussing it and listening to the video trying to decide if it was abuse or not, but we had already let her go. In an interview on 09/18/25 at 5:18 PM, the Admin stated he found out about the issue between Resident #5 and LVN D when the ombudsman told him on Monday, 09/15/25, and he was out of the facility for a few days between 08/24/25 and 08/30/25. The Admin stated, the SW and I went over to talk to Resident #5, and she showed me a video where LVN D is telling the CNA H that she shouldn't be taking 45 minutes to change the resident. [Resident #5] was telling [LVN D] to get out of the room and [LVN D] kept talking to the CNA instead of leaving. I decided to report it to state even thought I hadn't even completed my investigation yet. When I listened to it, then I looked over the rules and regulations, I wanted to make sure that it would fall under verbal abuse. The more I looked at the video, I don't think she (LVN D) was trying to threaten her (Resident #5) or make her feel afraid, and [Resident #5] said she wasn't afraid of her, but I couldn't find anything that made me feel like it was abuse. The Admin stated that being rude and ugly toward someone did make it reportable and they let her go because they did not want her to be rude or ugly to anyone else. The Admin stated no one told him anything prior to 09/15/25. The Admin stated, For the most part, he did see the grievances. The Admin stated in the mornings he would ask the SW if there were any issues. He further stated he would ask for grievances at every morning meeting. The Admin stated he was surprised to know that there was a grievance about this issues before he heard it from the ombudsman. The Admin stated, If the DON had told me about that grievance, I would have reported it. Once I find out about abuse it's 2 hours to report, everything else is 24 hours. Once I saw the video, I reported it. The DON saw the video first and she came back and told me she was not sure if it was abuse or not, so then I went in with the SW and watched it, talked with corporate, then decided to report it. The Admin stated they had abuse/neglect in-services every month on the 15th. Record review of the facility's self-report dated 09/15/25 reflected in part:The facility was notified of the incident on 09/15/25 by the ombudsman.The facility's investigation summary stated, On the above date and time, the alleged victim advised that an LVN [LVD D] had spoken lo her very badly. Upon viewing the video of the incident, it showed that the LVN was telling the C.N.A., while in [Resident #5's] room, that she should not be taking 45 min. to clean her. [Resident #5] then became upset and started yelling for the LVN to get out. The LVN then staled to [Resident #5] that she was the charge nurse and that she would get out when she was finished talking to the C.N.A. Facility in-serviced staff on facility abuse and neglect policy. Responsible party, physician, police department and THHS were all notified of the incident. The facility's investigative findings were, Inconclusive. Provider Action Taken Post-Investigation: In-service staff on facility abuse and neglect. Subsequently alleged perp. was terminated.Record review of the facility's undated Abuse Prevention policy reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.CORRECTIVE ACTION:Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.Record review of the facility's undated Abuse Investigation and Reporting policy reflected in part: Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting:1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. the local/State Ombudsman2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orb. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.5. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA-A yelled at and ridiculed Resident #1 on 10/16/2025 as he was requesting assistance. These failures could place residents at risk of physical, mental and emotional decline, psychosocial harm, as well as result in isolation and withdrawal.Findings included: Record review of Resident #1's face sheet, dated 10/16/2025, revealed an [AGE] year-old male first admitted to the facility on [DATE], and a readmission date of 11/18/2024. Pertinent diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow), major depressive disorder (a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (nagging feelings of worry or anxiety). Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/2025, revealed a brief interview for mental status was not completed. The MDS also revealed Resident #1 had a short-term and long-term memory problem, and cognitive skills for daily decision making were severely impaired. The MDS also revealed Resident #1 was dependent in bathing, dressing, and toileting. Record review of Resident #1's care plan, dated 05/01/2023, revealed Resident #1 required assistance for ADLs and mobility tasks due to generalized weakness, poor endurance, activity intolerance, and impaired balance. The care plan also indicated Resident #1 was status post CVA (stroke) with Vascular Dementia and Cognitive Communication Deficits (difficulties which arise from impaired cognitive functions such as attention, memory, reasoning, and problem-solving), as well as Aphasia (a communication disorder which results from damage to the areas of the brain responsible for language). Record review of Form 3613-A, Provider Investigation Report, dated 10/16/2025, revealed an allegation of abuse was confirmed when CNA-A yelled at Resident #1. Resident #1 was moved from CNA-A's area, and CNA-A was suspended and subsequently terminated. The RP, physician, MD, HHSC, PD, the DON, and the RDO were notified. A head-to-toe assessment of Resident #1 was conducted, with no injuries found. The PIR also indicated Resident #1 was interviewable with capacity to make informed decisions. The witness statement made by the Administrator in the PIR, dated 10/16/2025, revealed the Administrator was advised that CNA-A was shouting down the hallway toward Resident #1. The tone of his voice could be construed as verbal abuse. The SW spoke to Resident #1, and no emotional distress was discovered. Resident and staff interviews were conducted. No one advised of witnessing abuse or neglect. In an observation on 10/16/2025 at 11:23 AM, this surveyor observed CNA-A walk past the nurse's station heading toward and down the 200 hall, while yelling down the hall at Resident #1 you can do it yourself. If you want something you need to learn how to do it yourself. I am not going to help you. Resident #1 was observed to be holding his coffee cup and looking at staff behind CNA-A and at the nurses' station while CNA-A continued to raise his voice with him. CNA-A began stating again Do not look at them, they are not going to help you. You have to learn to do things yourself. RN-B was observed walking up to CNA-A and telling him You need to tone it down. State is in the building and standing right over there, to which CNA-A looked up toward the nurses' station and replied I don't care. It's called tough love. In an interview on 10/16/2025 at 11:40 AM, the DON stated CNA-A could be loud when he spoke to the residents, but she had never heard him scream or yell or speak down to them. She stated if she had ever heard CNA-A act this way in the past, she would have started an investigation for abuse and probably terminated him. The DON stated CNA-A was suspended immediately for this incident, and he was not answering his phone, as she had attempted to contact him to discuss suspension and termination with him. In an interview on 10/16/2025 at 11:55 AM, the SW stated raising your voice and speaking down to the residents was considered verbal abuse. She stated she had never had any reports or grievances from residents regarding CNA-A, but he could be very loud at times. The SW stated when CNA-A first started working here, he used a lot of curse words around the residents, and he was really loud. He had to be told to tone it down multiple times, and he had toned it down a lot. In an interview on 10/16/2025 at 12:04 PM, Resident #1 shook his head up and down (yes) when asked if the language and tone CNA-A used with him made him feel sad and embarrassed. He was observed to be shaking his head yes and saying Si [meaning yes in the spanish language]. He was also observed to be looking down and his eyes watering while answering the questions. In an interview on 10/16/2025 at 12:15 PM, the Administrator stated he had never heard CNA-A yell at the residents before, but the bottom line was this was verbal abuse, which was why he walked out of his office when he heard him yelling, and he had already suspended CNA-A and planned to terminate him. The Administrator stated actions like these were not okay and would not be tolerated. In an interview on 10/16/2025 at 12:15 PM, RN-B stated even though Resident #1 could not verbalize very well since his stroke, he was able to answer simple yes and no questions well. She stated she had never seen CNA-A yell at residents in the past, but he was loud. RN-B said the tone and verbiage used by CNA-A was considered verbal abuse and could cause mental or psychosocial harm to a resident. She stated CNA-A had been told to tone it down in the past. In an interview on 10/16/2025 at 2:50 PM, Resident #5 stated he liked CNA-A and got along well with him. Resident #5 denied CNA-A ever talking down to him or yelling at him. Resident #5 stated CNA-A tried to get people to help themselves, but he denied any abuse by CNA-A or the facility in general. In an interview on 10/16/2025 at 2:55 PM, Resident #6 stated CNA-A has never yelled at him or talked down to him. He stated he and CNA-A picked on each other, but not in a mean or abusive way. He denied any abuse by CNA-A or the facility. In an interview on 10/18/2025 at 1:47 PM, CNA-C stated she typically worked the 200 hall and had worked with CNA-A in the past. CNA-C stated CNA-A was not typically loud, but she could hear him yelling the other day, 10/16/2025. She stated she had heard him tell residents to do it yourself in the past and stated the tone he used and the words used could have been considered verbal abuse. CNA-C stated since the incident on 10/16/2025, she had been in-serviced over resident rights, abuse, neglect and reporting abuse, as well as staff and care-giver burnout. She stated if she had witnessed the incident on 10/16/2025, and if it had not already been witnessed and reported, she would have reported CNA-A for verbal abuse to the Administrator and DON. In an interview on 10/18/2025 at 2:39 PM, LVN-D stated residents should be treated with respect and not spoken down to or yelled at. She stated since the incident on 10/16/2025 she had been in-serviced over resident rights, abuse and neglect, and staff burnout. LVN-D stated she would have made the Administrator and the DON aware if she had witnessed any type of abuse or neglect. In an interview on 10/18/2025 at 3:13 PM, LVN-E stated she was in-serviced over employee burnout and stress, abuse and neglect, and resident rights last night. LVN-E stated if she witnessed abuse or neglect, she would have intervened to stop the abuse, separated any staff and residents involved, then reported immediately to the Administrator, the DON and/or the ADON. In an interview on 10/18/25 at 3:21 PM, CNA-F stated she was in-serviced over the past couple of days regarding abuse and neglect and when and how to report it. She stated if she witnessed abuse or neglect, she would have reported to the ADON, the DON, and the Administrator. CNA-F was also in-serviced on staff burnout and resident rights, and she stated she was a people person and loved what she did, and yelling at or speaking down to a resident was never appropriate. Record review of the facility's Abuse and Neglect and Resident Rights in-service, dated 10/16/2025, revealed A CNA may be reported for an act, or acts, in violation of a resident's rights. An act may involve abuse, neglect, and/or misappropriation of the resident's property. CNAs must have a clear understanding of these terms and their definitions. A CNA must also understand that the severity of penalties involved if a violation is reported, investigated, and proven. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is the failure to provide goods or services. Patient expectations: In addition, allowing residents the basic rights afforded to them, CNAs must also work to ensure that the environment practices respect, safety, and ensures privacy of each resident. Record review of the facility's Statement of Resident Rights, dated 07/20/2019, revealed you, as a resident, do not give up rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. Dignity and Respect: You have the right to be free from abuse, neglect and exploitation. Record review of the facility's Abuse Prevention Policy, no implementation or revision date noted, revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. As a part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for one (R#3) of 4 residents reviewed for injuries of unknown origin. The facility failed to ensure a resident remained free from an injury of unknown origin. Resident #3 suffered a dislocated shoulder and a later identified broken elbow . This failure could place residents at risk for further accidents and injuries. Findings were: Record review on Resident #3's face sheet dated 10/02/24 revealed the resident was admitted on [DATE] with the following diagnoses: vascular dementia, primary osteoarthritis, and other specified bone density and structure, affective disorder , anxiety due to physiological condition, depression, and glaucoma. Record review of Resident #3's Minimum Data Set, dated dated dated [DATE] revealed resident had a BIMS score of 00 (resident unable to complete this part of the assessment). MDS also indicated the resident had moderately impaired vision, rarely understands others, and was completely dependent on staff for mobility. Review of Resident #3's Care Plan undated indicated the resident had a potential for unrelieved pain due to impaired cognitive/communication abilities due to dementia. Further review of the care plan also indicated the resident was not able to participate in a BIMS assessment due to impaired short term and long-term memory, problem solving, and safety awareness. This care plan also indicated Resident #3 was disoriented and had poor decision-making abilities with Dementia. The care plan indicated Resident #3 was bed bound and was dependent X2 staff for transfer tasks with the mechanical lift. Record review on October 4, 2024, at 10:00 a.m. of provider investigation revealed Resident #3 was sent to the hospital on September 29, 2024, for complaint of pain in her left arm. Record review of provider's investigation 3613 at 9:30 a.m., indicated three staff were suspended pending the internal investigation, the shoulder was dislocated, and a witness statement from LVN C indicated staff did notify the Nurse Practitioner appropriately. An in-service was completed for staff on 09/30/24, and CNA E's witness statement indicated repositioning the resident in the shower completed appropriately and with no issues or concerns . Record review of Hospital Emergency Department admission notes dated 09/29/24 revealed Resident #3 had a slight widening of the acromioclavicular articulation (possible shoulder dislocation). Further review indicated Resident #3 was not a good historian and did have a deformity and dislocation of the right upper extremity on exam. During an interview on October 4, 2024, at 6:17 p.m., LVN B stated that when she arrived for her shift, she and RN A did an assessment on Resident #3, and they did not note any abnormality of the arm or injury. LVN B said the Nurse Practitioner was contacted and briefed on Resident #3's pain complaint and the Nurse Practitioner gave an order to administer acetaminophen and monitor the resident for effectiveness. LVN B said the acetaminophen was administered and it was effective with the pain and allowed Resident #3 to rest. LVN B said Resident #3 did say someone hurt her but could not provide specifics and this was communicated to the lead nurse. LVN B said Resident #3 had a diagnosis of dementia and history of saying she was in pain, so the Nurse Practitioner followed up and ordered a mobile x-ray later in the shift. LVN B stated the x-ray was delayed because the technologist did not come to the facility before her shift was over for the day. During an interview on 10/04/24, at 12:07 p.m., LVN C stated on 09/28/24 she we went to assess Resident #3 during her shift and the resident complained of pain. LVN C said she reviewed the shift report from the previous shift and noted that only acetaminophen was administered, and the x-ray was still pending. LVN C said when she re-assessed Resident #3, she was experiencing pain and was holding her arm in an abnormal way. LVN C said she called the NP and obtained an order to send Resident #3 to the hospital for evaluation. During an interview on October 4, 2024, at 5:12 p.m., the Nurse Practitioner, stated he was notified by a staff member (unsure which staff member and exact time of day) of Resident #3 having pain in the arm in the late afternoon on 9/28/24 and ordered PRN Tylenol and an x-ray. Later the same day or early the next day, (during sleep hours) he was notified the resident did not receive the x-ray due to a technician not being available and agreed for Resident #3 to be sent to the hospital. The Nurse Practitioner stated this injury could be from poor transferring or poor repositioning and he believed the nursing staff contacted him appropriately given they did not know the x-ray technologist would not be available. During an interview on 10/04/24, at 12:44 p.m., Resident #3 stated she was wheeled back to her room on 9/28/24 and placed in bed where someone then got on top of her and straddled her and tried to pull her up in her bed. They jerked her forward and back while trying to move her up in the bed. She yelled for them to stop and eventually they did. This wass what happened to hurt her arm. Resident #3 stated she had never seen this CNA, and this was not a usual staff member. During an interview on 10/10/24, at 1:35 p.m., the Director of Nurses (DON) stated Resident #3 had sustained a dislocated shoulder according to the emergency department. Resident #3 claimed she was injured on 9/28/24 but cannot identify the perpetrator and all staff have been questioned. The DON stated her expectations were for the nursing staff to be the eyes and ears of the physician. When the x-ray technician did not show u p the resident should have been sent to the emergency room . During an interview on 10/10/24, at 2:04 p.m., the Administrator stated an investigation had been completed, but there was no conclusive finding at this time. The Administrator confirmed all staff working on this day were facility staff and not agency staff. Resident #3 was still at the hospital with a dislocated shoulder and now a fracture of the elbow. The Administrator stated the nurses did treat the pain with medication and the resident rested for a bit. The next shift the nurse did talk with the Nurse Practitioner (NP) and got more medication and an x-ray ordered and sent the resident to the hospital per the NP orders when the x-ray technologist did not show up . During an interview on 10/30/24, at 9:40 a.m., CNA E stated she and CNA F did reposition Resident #3 the morning of the incident and completed the action accurately and according to policy and protocol. CNA E stated she was suspended after the incident and will not be returning to the facility due to the work being extremely stressful. During an observation on 10/04/24, at 1:50 p.m., CNA A and CNA B demonstrated transferring a resident appropriately and according to policy and protocol. During an observation on 10/31/24, at 11:05 a.m., CNA C and CNA D demonstrated transferring of a resident in a Hoyer lift appropriately and according to policy and protocol .

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for 1 of 5 residents (Resident #1) reviewed for neglect and abuse. The facility failed to report verbal abuse by the SA to local law enforcement in accordance with state law on 04/29/24 The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the undated facility Abuse, Neglect, and Exploitation policy stated the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: b). Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Procedure: A. Steps to prevent, detect, and report: Screening: Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security act's time limits for reporting a reasonable crime (immediately but no later than 2 hours if serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. Record review of the facility policy reference to Section 1150B of the Social Security Act: Guidance for Reporting Suspicion of a Crime. Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility to State Survey Agencies and Law Enforcement. Record review of Resident #1's face sheet revealed a [AGE] year-old female with diagnoses including diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, left below the knee amputation. Record review of Resident #1's MDS Quarterly dated 05/28/24 revealed Resident #1 had a BIMS Score of 15 indicating no cognitive impairment and needed little to no assistance with all ADLs. Record review of the provider's investigation dated 05/01/24 described on 04/28/24, the smoking attendant became upset with Resident #1 and cursed at her twice telling her Fuck You each time during a smoking break. There was a total of 4 residents who attested to, witnessed, and confirmed the incident. The provider investigation included Penal Code Title 9 Ch. 42 Sec. 42.01 Disorderly conduct (a) a person commits an offense if he intentionally or knowingly: (1) uses abusive, indecent, profane, or vulgar language in a public place, and the language by its very utterance tends to incite an immediate breach of the peace (a-1) (d) An offense under this section is a class C misdemeanor. There was no Case # and local law enforcement were not contacted. There was a signed 1:1 Teachable Moment dated 04/29/24 between the ADM and the SA. The employee was suspended initially and in-serviced on the importance of respecting the residents. The details revealed the employ was in the smoking area and cussed at one of the residents. The SA was not available for interview. Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse reflected the in-service was conducted by the ADM with the SA on 04/28/24 and signed in ink by both. Record review of the SA's time sheets dated 03/21/24-07/10/24 documented he was sent home on 04/29/24 at 2:44 pm. He returned to work on 04/30/24 from 7:01 am-7:16 pm. The record showed he worked Tuesdays, Thursdays, and Saturdays regularly and occasionally on a Monday or Friday. The SA was never suspended for his verbal abuse, he was only sent home early as reflected on his time sheets In an interview with Resident #1 on 08/07/2024 at 9:48 am she stated the SA specifically said, fuck you and she asked him, what did you say to me? and he said it again, louder. Resident #1 stated this happened on the smoking patio and lots of other people were out there. She stated she reported it immediately to the SW who sent her to the ADM, and she told him about the incident. She stated, First the SW and DON told her they fired him (the SA), then suspended him, but then he was back. Resident #1 stated, Since then, he (SA) either quit or got fired probably 3-4 weeks ago. She said did not speak to him, nor him to her when he came back. She stated she saw him around 3-4 times, and became very anxious each time. She said seeing him would ruin her day. She said she did not know what she was afraid of but felt unprotected. She said she spoke with the SW and asked the ADM why the SA was still around. She said she asked to see the report he (the ADM) sent because he had gone back & forth with her about when & if he called the state. Resident #1 stated the ADM told her if she kept causing trouble, she could find herself on the street. She stated HR had joined their conversation and told her, The state had more to worry about than her. She stated the ADM was not joking with her and had raised his voice to her. In an interview with HR on 08/07/2024 at 11:09 am she stated she (Resident #1) came to me about the smoke guy (SA) and said, who the F was I to let this MF clean the patio when we trying to smoke. HR stated she had never had any situations with the SA, that he was a good guy. HR stated the SA just stopped coming to work on July 10, 2024, and that was the day she terminated him. She stated she tried to call him, but he never answered her calls. HR stated the SA came to pick up his check and he told her his truck broke, and that was that. She stated the ADM had to tell Resident #1 she could not speak that way to them. In an interview with the ADM on 08/07/2024 at 11:34 am he stated he was not at the facility during the first encounter Resident #1 had with HR because he was at lunch. He stated Resident #1 wanted to speak to him in his office and she said she told the SA he should not be doing that (washing the smoking patio) right then and that he (the SA) cursed at her. The ADM stated he suspended the SA immediately then reported it to the state for verbal abuse. The ADM stated the SA was allowed to return after his suspension and was moved to a different role (light maintenance and painting) so he would not have any contact with Resident #1. The ADM stated the SA ended up leaving/quitting. In an interview with Resident #1 on 08/08/24 at 9:41 am, she stated that she felt embarrassed and anxious because she did not like being talked to by the SA in such a negative way in front of other residents. She stated that she felt fear and anxiety seeing him (the SA) around the facility after the incident. The resident stated that when they did not get rid of him right away, she felt like the facility did not care to protect her. In an interview the ADM on 08/08/24 at 10:53 am, he stated, The findings were inconclusive because the man (SA) never admitted to saying fuck you to the resident. He said signing the 1:1 was not an admission of guilt, it only meant he received the 1:1 training. The ADM repeated that the SA never admitted to it. He said a teachable moment (the 1:1 training) was just a record of a verbal reprimand. The ADM said there was no policy that stated what the punishment was for abusing a resident. The ADM said his conclusion of his investigation was inconclusive. He stated the allegation met the definition of verbal abuse, but his findings were inconclusive. The ADM refused to answer whether the incident had reasonable suspicion of a crime (verbal abuse) if the smoking attendant said fuck you to the resident. The ADM stated, In my opinion verbal abuse does not reach the threshold of needing to call the police (meaning he did not notify local law enforcement). If you want to get me for not following my policy, then that is fine. The ADM stated he did not know if the social worker did wellness checks on Resident #1 after the incident. In an interview with the DON on 08/08/24 at 1:25 pm, she stated she talked with Resident #1 a few weeks after the incident, and she was concerned about the SA still working in the facility. She stated, I eased her concerns and said he would not bother her. I reported this to the administrator and the social services director. She stated she did not know if the ADM or SW spoke to Resident #1. In an interview with the ADM on 8/9/24 at 4:00 PM, he stated, The SA was suspended for 3 or 4 days, then he had some days off behind it, making it seem longer. The ADM had no comment regarding the SA's timesheets. Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance. Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. Record review of the facility's Abuse Prevention policy and procedure undated. Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse. The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents. The findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included depression unspecified (patient is primarily depressive but does not meet the full criteria for any specific depressive disorder) and type 2 diabetes mellitus. Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 05/29/2024 reflected a BIMS score of 15 (cognition intact). Record Review of Resident #5's face sheet reflected a [AGE] year-old male with an admitted [DATE]. Pertinent diagnoses included depression unspecified, generalized anxiety disorder, and alcohol-induced persisting dementia (damage to the brain caused by regularly drinking alcohol over many years resulting in memory loss and difficulty thinking things through). Record review of Resident #5's quarterly MDS assessment section C, cognitive patterns, dated 06/06/2024 reflected a BIMS score of 13 (cognition intact). Record review of Resident #6's face sheet reflected a [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included vascular dementia (general term for problems with reasoning, planning, judgement, memory and other thought processes), anxiety disorder, unspecified depression, and bipolar disorder (mental illness causing unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident #6's MDS assessment section C, cognitive patterns, dated 06/10/2024 reflected a BIMS score of 13 (cognition intact). Record review of the provider investigation report dated 05/01/2024 revealed that on 04/29/2024 The alleged perpetrator (SA) was in the patio washing the concrete area. This is when the alleged victim (Resident #1) started confronting the alleged perpetrator about washing the concrete during smoke break. According to witness' the alleged perpetrator became upset with the alleged victim and cussed at her. Once the facility was advised of the incident at about 2:15 PM., the Administrator suspended the alleged victim pending the outcome of the investigation. The provider investigation report found the results of the investigation to be inconclusive. Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #1 stating I went outside to have a cigarette after lunch. SA was wetting down the patio (smoke area) with the water hose, I asked why he was doing that, he said they asked him to. So I went inside to find his boss (HR) to tell her he was not passing cigarettes because he was cleaning the patio. She asked why I was telling her. I said because you are his boss and I went outside to where he was then pouring liquid soap. Then HR came out and asked if he was giving cigarettes out, he said in a few minutes, but he was on the first part of the patio. At this point I told him his head was a little big with his job, and I was tired of him being so controlling. He said fuck you, I said what did you say to me? He said it a little louder. I am not defending my behavior, but I did not deserve that. I went and to SSD, then administrator and my witnesses came forward and corroborated my complaint. The DON came and talked to me, and again before she left for the night. Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #7 stating I heard SA, the smoke monitor, tell Resident #1 'Fuck you.' 4/29/24 Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from FT stating On April 29th I was outside SA was scrubbing the patio and Resident #1 came outside and asked for a cigarette. He told her she had to wait she questioned why they had to wait and his reply was after she asked what did you say and he said 'fuck you.' Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse was conducted by the Administrator with the SA on 04/28/24 and signed in ink by both. In an interview with SM on 08/06/2024 at 10:41 AM, SM stated that the patio was open to residents that wish to smoke from 7 AM to 7 PM. SM stated there was a lunch break from 12 PM to 1 PM where the patio was closed for smoking. SM stated that he was familiar with SA and he had heard from residents that SA would frequently yell and cuss at all of them. SM stated he was not familiar with any specific incident involving Resident #1, and that he had not started working yet at the facility on 04/29/2024. In an interview with Resident #5 on 08/06/2024 at 1:07 AM, Resident #5 stated that SA would cuss and yell at all the residents in the smoking area. Resident #5 stated that he was aware of the incident involving Resident #1 when SA said Fuck you to her on 04/29/2024, but could not elaborate further on other incidents. In an interview with Resident #6 on 08/06/2024 at 2:49 PM, Resident #6 stated that SA told one of the ladies in the smoking area to Fuck off. Resident #6 stated that she was not there at the time of the incident, but that she heard it from everyone that goes out to the patio to smoke. In an interview with Resident #1 on 08/07/2024 at 9:50 AM, Resident #1 stated that SA said fuck you to her. Resident #1 stated that a lot of other residents were out there and heard it as well. Resident #1 stated that she immediately reported the incident to the Administrator. Resident #1 stated that SA was suspended, but that he came back to work as a maintenance person and that she had seen him walking around the building. In an interview with HR on 08/07/2024 at 11:09 AM, HR stated that the last day SA worked was on 07/10/2024. HR stated that SA was not fired after the verbal abuse incident. HR stated the reason SA no longer works at the facility was because he stopped showing up for work after 07/10/2024. In an interview with the Administrator on 08/07/2024 at 11:33 AM, the Administrator stated that, during the initial incident on 04/29/2024, Resident #1 was upset because SA was washing the patio and not handing out cigarettes. The Administrator stated that SA allegedly told Resident #1 to fuck off when she told him to stop cleaning the patio. The Administrator stated they reported the incident to Texas Department of Health and Human Services for verbal abuse and suspended SA. The Administrator stated that SA was suspended for a few days before returning to work, but he could not remember exactly how long the suspension lasted. In a follow-up interview with Resident #1 on 08/08/2024 at 9:41 AM, Resident #1 stated that when the incident first occurred, she felt embarrassed and anxious because she did not like being talked to that way in front of other residents. Resident #1 stated that after the incident, when she saw SA working in the facility, she felt fearful that he might confront her because she made him change job roles at the facility. Resident #1 stated that there was one incident once SA returned to work at the facility where he was painting other resident's doors outside her room in the 300 hall. Resident #1 stated that a lot of her fear and anxiety returned when she saw him so close to her room. Resident #1 stated that she felt like the facility did not care to protect her from him, or future aggressors if a similar event happened again. In a follow-up interview with the Administrator on 08/08/2024 at 10:53 AM, the Administrator stated that the findings of the provider investigation were inconclusive because SA never admitted to saying fuck you. The Administrator refused to answer if he had reasonable suspicion on whether SA said fuck you to Resident #1. The Administrator stated that verbal abuse of this nature does not reach the threshold of needing to call the police. The Administrator stated that the resident never voiced any concerns about SA still working at the facility. The Administrator stated that this incident did not violate Resident #1's rights because she could have waited a few minutes for her cigarette. The Administrator stated that he did not know if SSD did wellness checks on Resident #1 after the incident. In an interview with the SSD on 08/08/2024 at 1:20 PM, the SSD stated approximately two weeks after SA was suspended where Resident #1 saw SA painting the doors near Resident #1's room. SSD stated that Resident #1 was upset at that time, but SSD calmed Resident #1 down and let Resident #1 know that SA would finish his work soon. SSD stated that was the only incident she was aware of involving Resident #1 and SA after the incident on 04/29/2024. In an interview with the DON on 08/08/2024 at 1:25 PM, the DON stated that she talked with Resident #1 a few weeks after the incident and Resident #1 expressed concerns about SA still working in the facility. The DON stated that she reported this to the Administrator and SSD. Record review of the Time Card Report for SA revealed that on the day of the incident, 04/29/2024, SA clocked out at 2:44 PM. The Time Card report revealed that on the day after the incident, 04/30/2024, SA worked from 7:01 AM to 7:16 PM with a break from 11:57 AM to 12:37 PM. Record Review of the facility's undated policy titled Abuse Prevention defined Verbal Abuse as The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Following that, in the section titled PROCEDURE: STEPS TO PREVENT, DETECT AND REPORT: SCREENING: #3 stated It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Record review of the facility's policy titled Statement of Resident Rights dated 07/20/2015 stated under the DIGNITIY AND RESPECT section You have the right to: Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect. Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance. Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. Record review of the facility's Abuse Prevention policy and procedure undated. Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment. 50039

Based on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided for the resident's immediate care and needs for 1 of 5 residents (Resident #3) reviewed for physician services. The facility failed to ensure there were orders for R#3's type 2 diabetes mellitus with hyperglycemia. On 12/22/23 at 3:55 PM an Immediate Jeopardy (IJ) was identified., while the IJ was removed on 12/23/23 at 6:30pm, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of R#3's Face Sheet, dated 12/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus ( a chronic condition that affects the way the body processes blood sugar ) with hyperglycemia (high blood sugar), cerebral infarction (damage to tissue in the brain due to disrupted blood supply and restricted oxygen supply) unspecified, Osteomyelitis (infection of the bone), unspecified and urinary tract infection (infection in any part of the urinary system, the kidneys, bladder or urethra), site not specified. Record review of R#3's undated baseline care plan revealed a section titled DIABETES, with a goal of Efforts will be made to ensure symptom control without complication, Documentation in this section was comprised of check of questions and areas to be filled in. First line checked had a FSBS q (fingerstick blood sugars to be each/every) printed with AC/HS (before meals and at bedtime) written in. Third line was checked off and had Sliding Scale? printed with As ordered 12/15/23 written in. The 5th line that stated Monitor for S&S (signs and symptoms) of hypo/hyperglycemia (Low and high blood sugar) was not checked off and had no written documentation noted. Record review of R#3's undated MDS (Minimum Data Set) assessment received on 12/22/23 revealed R#3 had a BIMS score of 10 which meant the resident was moderately cognitively impaired. R#3's MDS also revealed he had clear speech, was able to make self-understood, and understood others. Record review of R#3's hospital's discharge summary dated 12/05/23 stated, T2DM (type 2 diabetes melilotus), SSI (sliding scale insulin), Continue glargine (insulin) 10 units and Monitor closely for worsening hyperglycemia (high blood sugar) in the context of Solu-Medrol (steroid). Record review of R#3's discharge home medication list from the hospital dated 12/05/23 did not include any diabetic medication, injection, or blood sugar checks. Record Review of R#3's Admission/Readmission data summary dated 12/06/23 and completed by LVN A stated R#3 had a diagnosis of Diabetes Mellitus and hyperosmolar hyperglycemic (life threatening complication from diabetes, happens when blood sugar is too high for long period of time, leading to severe dehydration and confusion). R#3 was documented as alert and able to make self-understood and understand others. LVN A documented that she verified medication with nurse from the hospital due to the improper list sent from the hospital and had the orders documented as verified with NP C (nurse practitioner) by LVN A. Record review of R#3's orders revealed he had no orders for any diabetic medication, injection, or blood sugar check until 12/15/23. Record review of R#3's orders revealed an order for CBC (complete blood count), CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) Q (every) week while on ABT (antibiotic therapy) IV (intravenous) dated 12/06/23. Record review of R#3's laboratory results date collected 12/09/23, revealed R#3's glucose result of 288mg/dL (reference range 70-100) and was flagged as high, no A1C (blood test that shows what your average blood sugar (glucose) level was over the past two to three months) was noted as ordered. Written note on this document stated Physician D was notified on 12/11/23 but did not indicate by who. Record review of R#3's nursing note dated 12/14/23 at 7:40pm by RN B stated R#3 appeared confused and agitated. R#3's speech was impaired and was unable to be understood and was unable to answer simple questions. Vitals were documented however there was no fingerstick blood sugar completed. Record review of R#3's transfer form completed by RN B on 12/14/23 at 7:40pm stated R#3 was sent to the emergency room due to a change in LOC (level of consciousness). Record review of R#3's hospital document titled Patient Visit Information dated 12/14/23 stated R#3 was seen for hyperglycemia, UTI, and dehydration. This document also included Dr's instructions to Make sure that you are checking your blood sugars and having them taken care of with your medicines. You were found to have a urinary tract infection. There is no evidence of diabetic ketoacidosis today. During interview with hospital staff member on 12/21/23 at 12:34pm, hospital staff member reviewed R#3's hospital stay information from 12/14/23, she stated blood sugars taken by the EMS who transported resident read high and did not provide a numerical reading. R#3's blood sugar was taken at the hospital on 12/14/23 at 8:51pm and it was at 647. R#3 was given 15 units of insulin. R#3 was found with a primary impression of hyperglycemia, a secondary impression of UTI, and dehydration with discharge instructions provided on 12/14/23 at 11:57pm. R#3's hospital documentation has been requested but not yet received as of 01/04/23. During an interview with NP C on 12/20/23 at 4:43pm, he stated he did not recall if he had ordered an A1C for R#3. He stated an A1C should have been ordered. NP C stated diabetic patients should be put on monitoring and did not know why R#3 was not. NP C stated R#3 should have been put on insulin per protocol with a sliding scale, blood sugar check, and lab work. NP C stated he was at the facility on 12/09/23, 12/10/23, and 12/11/23 and he reviewed R#3's medications and chart. He stated, for whatever reason it went right over my head and there was a decrease in observance in this one particular item. During an interview on 12/22/23 at 2:45pm with LVN A, she stated she was the admitting nurse when R#3 was admitted . She stated when R#3 came into the facility the medication list she received was not the same one they usually receive. LVN A stated she called the nurse at the hospital to go over the medications and to check if it was correct. LVN A stated the only changes made was to the blood pressure medication. LVN A stated she did not recall if she asked the hospital nurse about insulin. LVN A stated she asked the hospital nurse if anything else needed to be added and she told her no. LVN A stated R#3's admission paperwork did state he had diabetes but did not have orders for insulin or blood sugar checks. LVN A stated she called NP C and went over the medications. LVN A stated when she asked about the labs, NP C stated he would go over the hospital labs and would see R#3 when he was at the facility. LVN A stated she had told NP C about R#3's diagnosis of hyperglycemia and NP C did not add any new orders. LVN A stated she did not recall if she asked NP C about blood sugar checks. During an interview with RN B on 12/27/23 at 8:47am she stated on 12/14/23 she had been rounding on R#3 and he was in bed acting normal. RN B stated right before 8:00pm R#3's family went to RN B and told her they thought something was wrong with R#3. RN B stated when she entered R#3's room she noted him to be all over the bed and he looked completely different. RN B stated R#3 was flopping about the bed but not purposely, and he appeared anxious and unable to focus. RN B stated R#3 looked at her like a stranger and she knew he was checked out. RN B stated she took one look at his pupils and called 911. RN B stated R#3 had a serious change in LOC (level of consciousness). RN B stated she had no idea what happened to him. RN B stated she took R#3's vital signs. She stated they were not horrible or wonderful. She stated at the time R#3's blood pressure was running high and was not unexpected. RN B stated she did not take blood sugar reading for R#3,she did not know R#3 was diabetic, but later in the interview she stated she knew he was diabetic. RN B stated R#3 did not have any orders for blood sugar checks, diabetic medication, or insulin. RN B stated when the EMS staff (emergency medical service) arrived R#3 had a blood sugar reading greater than 500 per EMS. RN B stated she never asked NP C or Physician D about orders for blood sugar checks or diabetic medication/insulin. During an interview with NP C on 12/27/23 at 9:10am, he stated the process for medication reconciliation upon admission was the staff should call him to review the medication discharge list with him. He stated, to see if they want to keep the medications, add, or subtract medications. NP C stated he could not recall if someone called him to go over R#3's medications. NP C stated everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. NP C stated he did not know if he knew R#3 was diabetic on 12/06/23. NP C stated he was aware R#3 was a diabetic when they told him R#3 had elevated blood sugars and they treated him immediately. NP C stated protocol for a regular diabetic would be to start them back on medication, sliding scale insulin, to monitor daily blood sugars throughout the day, and get lab work completed. NP C was asked about R#3's lab results from 12/09/23 and he stated a glucose level of 288 was considered elevated. NP C stated he usually does not treat unless glucose is over 150 and it depended on the patient's compliance. NP C stated he did not remember if any staff from the facility including the DON, or nursing staff asked him or physician D about adding blood sugar checks and/or diabetic medication/insulin. NP C stated he did not know why nothing was put in place for R#3 until 12/15/23. When asked about the facilities policy regarding monitoring, supervising, and getting orders for diabetic medication, insulin, and blood sugar checks NP C stated he did not know. He stated they had protocols but not everyone got blood sugar checks. NP C stated a resident would have to be assessed to see the circumstances before testing them. NP C stated he monitored residents to ensure appropriate orders were in place for their needs by rounding on them multiple times a month, reviewing their medications, looking at notes, and speaking with nursing about any incidents or concerns that may have occurred between his visits. He stated he also visits with the residents. NP C was asked how not monitoring blood sugars or not administering diabetic medication/insulin to a diabetic can negatively impact them, and he stated it was not that the resident was not monitored. He stated when he received the elevated sugars he was treated immediately. NP C stated he reviewed R#3's medications and stated he managed medication and symptoms as they presented themselves. During an interview on 12/27/23 at 9:51am with LVN A, she stated depending on the orders, the admitting nurse or anyone such as the ADON or the DON who checked the admission afterwards, would be responsible for identifying if a resident was diabetic and required blood sugar checks. LVN A stated when working and receiving a new patient with a diagnosis of diabetes, she usually looked for any oral diabetic medications, insulin, or sliding scales. During an interview with Physician D on 12/27/23 at 10:51am, he stated the process for medication reconciliation upon admission was for the admitting nurse to discuss whether to continue or hold medications with the mid-level professional (NP C). If the mid-level (NP C) was not available the admitting nurse would discuss medications with Physician D. Physician D stated he did not get the initial admission so it would have been his mid-level, NP C. Physician D stated all of us were responsible for ensuring residents had the appropriate orders to meet their needs and maintain their safety. Physician D stated he had reviewed R#3's hospital information and the note he saw on the discharge summary stated R#3 was diabetic and hyperosmolar hyperglycemia state. He was aware R#3 had been given 10 units of insulin and on a sliding scale due tohis sugar level that went up to 600 and required an increase of insulin to 20 units. Physician D stated he read where it stated to monitor and watch for hypoglycemia when tapering the steroid (Solu-Medrol). Physician D stated the way it was written, was as if R#3's blood sugars were rampant due to the steroid he was taking, and saw it as R#3's increase in sugar levels were steroid induced. Physician D stated when R#3 was discharged from the hospital his discharge medication list had no diabetic medications. Physician D stated he checked with the DON to see if anything was communicated from the hospital nurses to facility nurses about blood sugar checks, insulin, diabetic medication, or if R#3 was diabetically fragile and the DON stated no. Physician D stated they were monitoring R#3's labs and there was 1 lab done on admission. He stated the blood sugar was trending down after the initial admission labs. Physician D was asked about R#3's lab results from 12/09/23, Physician D stated he thought he saw those lab results on 12/13/23 or 12/14/23. Physician D stated glucose of 288 was high but not critical and stated R#3 still had the steroid in his system. Physician D stated he did not give any new orders at that time for blood sugar checks or diabetic medication or insulin. Physician D stated they had discussed blood sugars and previous steroids and decided they would continue to monitor and see how it was trending. Physician D stated ideally, yes, a diabetic would get fingerstick blood sugar checks and an A1C. He stated they did not get communication, so the transition of care was poor, and took a little long for them to pick up on the issue. Once it was picked up, they acted immediately. Physician D stated R#3 went to the hospital and ended up having a UTI. Physician D stated R#3 did not have any orders for blood sugar checks or diabetic medication/insulin because they were not aware. He stated if they knew they were diabetic then blood sugar checks, A1C, and diabetic regimen based off labs would be protocol. Physician D stated no staff asked him or NP C about adding blood sugar checks or diabetic medication/insulin. Physician D stated he was not personally notified of R#3's change in level of consciousness on 12/14/23. He stated that would have gone through NP C. Physician D stated based on facility policy if they knew 100% the resident was a diabetic and depending on their needs, would require various monitoring such as more frequent blood sugar checks, sliding scale, and A1C several times a year to adjust regimen. Physician D stated he monitored residents to ensure appropriate orders were in place for their needs through the DON. The nursing staff look at the resident and communicate anything that had come up with himself or NP C during their visits. Physician D stated, this was a one off because from the hospital side what transpired and their lack of whatever. Physician D stated not monitoring blood sugar checks, A1C's, and not administering diabetic medication and insulin to a diabetic resident could negatively impact to become hypoglycemic or hyperglycemic. During an interview with the DON on 12/27/23 at 3:55pm, she stated the process for medication reconciliation upon admission was for the admitting nurse to review medication with the nurse practitioner or physician. The DON stated on 12/07/23 she reviewed R#3's chart thoroughly and went over it with Physician D and they agreed to stay with the medication and regimen the way it was. The DON stated she was aware R#3 was a diabetic in the context of Solu-Medrol (steroid) and had not read the part in the hospital discharge summary that stated to continue with blood sugar monitoring due to high sugars. She stated she did not go based off that because it was from 12/05/23 and he was discharged [DATE]. The DON stated R#3 was not sent with any insulin and when LVN A reviewed medications with the nurse from hospital she did not say anything. The DON stated Physician D received R#3's updated chart on 12/07/23 when she reviewed it with him. She stated NP C got the information in their general admission email. The DON stated LVN A had documented that she went over the medication list with NP C. The DON was asked about R#3's lab results from 12/09/23 and stated a glucose level of 288 was considered high. The DON stated when she spoke to Physician D on 12/11/23, about labs from 12/09/23, they also reviewed labs from 12/06/23 in the hospital and stated they noted a lower glucose than his hospital labs on 12/06/23. The DON stated she received a call back on 12/11/23 at 11:32am and received no new orders for diabetic interventions, insulin, or blood sugar checks. The DON stated she followed the physicians' orders and stated Physician D was convinced R#3's blood sugars were in the context of Solu-Medrol (steroid). The DON stated she reviewed with Physician D and he was saying they were going in the right direction that the Solu-Medrol was going out of R#3's system and his glucose was decreasing. The DON stated the nurse (LVN B) on 12/14/23 documented that R#3 had a change in level of consciousness and told her R#3 could not get his words out correctly. The DON stated they do diabetic protocol as ordered by the physician. The DON stated she monitored residents to ensure appropriate orders were in place for their needs by collecting all orders from medical records every morning and making sure they were in place. She stated she will run order audits, especially with labs stating she would note any abnormal labs and if physician was notified. The DON stated normally they were on their diabetic residents, stating it was just this one case that was different because of the Solu-Medrol. The DON was asked how not monitoring blood sugars, not administering diabetic medication/insulin to a diabetic can negatively impact them and she stated they could go into diabetic keto acidosis (DKA- A serious diabetes complication where the body produces excess blood acids). During an interview on 12/27/2 at 4:50pm with R#3, he stated on 12/14/23 his sugar was too high. R#3 stated when he was in the hospital prior to arriving at the facility they were giving him shots (insulin) and when he arrived at the facility the shots stopped. R#3 stated when he was at the facility he was not on insulin and took his medications and thought he was on Metformin (diabetic medication). R3# stated at time of incident on 12/14/23 he was not having his blood sugar checked at the facility. Record review of the facility's Policy titled, Resident Assessment Admission Orders with an effective date implemented 11/28/2017 stated, The facility must have physician orders for the residents immediate care. Record review of the facility's Policy titled, Physician Services/Physician Supervision with an effective date implemented 11/28/2017 stated, A physician must supervise the medical care of each resident. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 3:55 PM. The administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 12/22/23 at 4:08pm The following Plan of Removal (POR) submitted by the facility was accepted on 12/23/23 at 12:06 PM: PLAN OF REMOVAL F710 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of physician services: Regional Director of Operations re-educated Administrator on ensuring residents were receiving necessary and accurate physician services on new admissions on 12/22/2023. Regional Nurse Consultant for facility educated Director of Nursing on receiving practitioner's intended protocols for alleged deficient practice as related to physician services on 12/22/2023. Licensed facility personnel to perform audit on all current residents to assess diagnoses that could require order for diagnostics and present to practitioner for evaluation and orders as determined by primary care practitioner or designee. 12/23/2023. DON/designee to have complete re-education of licensed nursing personnel on new admission orders, including communication with the practitioner about diagnostics and diagnoses as ordered by practitioner by 12/23/2023. Facility DON and administrator discussed findings from survey allegations with medical director and practitioner responsible for resident care in question with understanding of allegation noted and medical director implementing standing orders for labs to indicate further monitoring needed upon MD, and practitioner under his/her direction, assessment of findings from labs drawn. Orders to be given by MD and/or practitioner under his/her direction, based on their clinical expertise and licensing, with facility to follow orders as indicated. 12/22/2023 Protocol to be initiated for lab and diagnostics on new admissions as facility practitioner designates and orders by 12/23/2023. Interventions and Monitoring Plan to Ensure Compliance Quickly: oThe Director of Nursing/Designee educating all licensed nursing staff on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders. Initiated: 12/21/2023 Completion: 12/23/2023 oStanding orders for admission labs received from medical director with follow up orders on continuation of labs to be determined by practitioner according to findings and evaluation of individual resident needs. Initiated: 12/22/2023 Completed: 12/22/2023 oNew admission order assessment and completion audits will be completed 3 times a week for 4 weeks and then weekly from thereafter by DON/ADON/Designee. Initiated: 12/22/2023 Completion: 12/23/2023 oImmediate action to notify physician and receive new orders on residents identified through audit findings for potential adverse notations in diagnostics with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 oStaff that are on leave from the facility will be re-educated by DON/ADON/Designee on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. oFacility will initiate weekly admission meeting with interdisciplinary team to review previous week admissions to include physician and/or designee for re-verification of orders. Initiated: 12/22/2023 Completion 12/23/2023 oAudit sheets for admissions to be reviewed by DON/ADON/Designee for completion at least weekly during facility admission meeting. Initiated: 12/22/2023 Completed: 12/23/2023 oThe policy and procedure already in place for orders and physician services was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policy on physician services as previously implemented, to include any new procedures as ordered. Initiated: 12/22/2023 Completed: 12/23/2023 oFacility Administrator will ensure implementation and completion of interventions through individual communication with team members and medical practitioners, as well as weekly CAR meetings and QAPI meetings as indicated below. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate physician services, including new admission orders, are followed and maintained per current facility policy on physician services. The Medical Director was notified of Immediate Jeopardy on 12/22/2023 and will be part of the QAPI intervention meetings. Procedures on new admissions and physician services to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. The state surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Interview with the Administrator on 12/23/23 at 12:45 PM revealed he was responsible for ensuring all POR interventions were implemented. The Administrator said he implemented a meeting with all IDT every morning Monday-Friday (initiated 12/22/23) to discuss corrective action plan coordination, completion, and follow-up for 3 weeks. The Administrator said he would review all in-services and along with IDT, would review all new admission orders for maintenance of the facility's physician services policy. The Administrator said the IDT, including himself, would discuss and review POR/POC status monthly for the next 3 months. Interview with the DON on 12/23/23 at 12:59 PM revealed she acknowledged she received training and provided her nursing staff training on: Standing Laboratory Orders (new procedure implemented after IJ) to include: CBC, CMP, HA1C, TSH, Lipid Panel (blood test to measure amount of cholesterol and triglycerides in your blood), Pre-Albumin (a protein that's made by the liver) for all new admissions to get a baseline of each resident. The DON said she also provided in-servicing for her licensed staff regarding Admission documentation to include medication reconciliation, known history, diagnostics, and assessments. The DON said she informed/reminded her licensed staff on immediate notification of physician upon new admissions, reviewing of medications, orders, and history of diagnoses. The DON said she and her ADON conducted 100% of chart reviews which included 49 residents with a history of or current diagnosis of diabetes. The DON said 9 residents did not have a HA1C, or diabetic blood glucose monitoring ordered so their physicians were called and lab and monitoring orders were received. The DON added that 9 residents receiving hospice services did not have any labs ordered which the physicians were contacted, and orders remained the same. The DON said she implemented a Monitoring Tool - Admission Audit Form which she and the ADON were responsible for conducting audits of every new admission to ensure: consent for treatment were received, Notify Physician of Admission, Diagnosis, Meds, Diagnostics, Lab Standing Orders initiated, Documentation of medications, dx, diagnostics .The DON stated the audits would continue for at least 3 months and results would be reviewed by IDT monthly in QAPI meetings. Interview with the following staff on 12/23/23 revealed they were able to verbalize the procedure for reporting a change in resident condition which included to immediately notify the nurse of any change in condition: 1:05 PM - CNA E (6A-2P shift) 1:15 PM - CNA F (6A-2P shift) 1:27 PM - CNA G (6A-2P shift) 1:35 PM - CNA H (6A-2P shift) 2:00 PM - CNA I (2P-10P shift) 2:13 PM - CNA J (2P-10P shift) 2:22 PM - CNA K (2P-10P shift) 2:28 PM - CNA L (10P-6A shift) 2:33 PM - CNA M (10P-6A shift The following staff (from different shifts) were interviewed on 12/23/23 and revealed all staff were trained on 12/22/23 regarding Admission Standing Lab Orders, Physician Services, Admission Documentation, Contacting Physician of New Admissions, Diabetic Monitoring. All staff were aware and verbalized the procedures per the facility's policy and procedures. 2:48 PM - LVN N (7P-7A shift) 3:20 PM - LVN O (11P-7A shift) 3:32 PM- LVN P (7P-7A shift) 3:40 PM -LVN Q (7A-3P shift) 3:56 PM -RN R (Weekend/PRN shift) 4:10 PM -LVN S (7A-3P shift) 4:29 PM -LVN T (7A-3P shift) 4:40 PM -RN B (7P-7A shift) 4:57 PM - LVN U (3P-11P shift) Record review of the facility in-services provided by the Regional Nurse Consultant reflected the DON received education on 12/22/23 Regarding Physician Services specifically addressing oversight by the DON of monitoring adherence to current policies and procedures for physician services and order reviews to include lab monitoring for specific diagnoses and documentation of physician or practitioner preferences and orders. Understanding of all education verbalized with plan for QAPI utilization and involvement as well as audits in place for monitoring of adherence. Record review of the facility in-services provided by the Regional [NAME] President of Operations reflected the Administrator received education on 12/22/23 Regarding the importance of physician services specifically addressing oversight and monitoring adherence to current policies and procedures for physician services and order reviews. Record review of the facility in-services provided by the Administrator reflected the Physician D and NP C received education on 12/22/23 Regarding Physician Services, specifically the indication of monitoring of diagnoses to be addressed on a case-by-case basis. Both individuals acknowledged their understanding of monitoring of said diagnosis. Interview with NP C on 12/23/23 at 5:14 PM revealed he acknowledged he received training regarding physician orders, specifically ordering lab, monitoring, and treatment for specific diagnoses: Diabetes. The NP said moving forward he will ask every nurse who call and/or report to him of any resident if the resident was diabetic and if Hemoglobin A1C and daily monitoring was ordered. Record review of the following resident records revealed they had a diagnosis of diabetes mellitus and had a HA1C and an order for diabetic glucose monitoring; Care plans were current and reflected diagnosis: -R#3 -R#6 -R#7 -R#8 The Administrator was informed the Immediate Jeopardy (IJ) was removed on 12/23/23 at 6:30PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure services were provided using proper safety techniques to prevent accidents for 1 of 3 resident reviewed for accidents, Resident #2 (R #2) in that: The facility failed to ensure the Dietary Aide checked temperature of soup given to resident resulting in R #2 sustaining a second degree burn injuries. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 05/12/23 and ended on 05/17/23. The facility corrected the non-compliance before the investigation began. This failure could lead to the injury of residents that are served hot foods/beverages/liquids. The findings included: Record review of Resident #2's (R#2) clinical file revealed a [AGE] year-old male, with an original admitted [DATE]. Diagnoses included, Heart Failure, lack of expected normal physiological development in childhood, Cellulitis (bacterial infection of the skin), Edema (swelling caused by too much fluid trapped in the body's tissues), Shortness of Breath, Bilateral Osteoarthritis of hip (cartilage in the hip joint gradually wears away), Idiopathic Aseptic Necrosis of Femur (death of bone tissue due to interruption of the blood supply), Type 2 Diabetes (insufficient production of insulin causing high blood sugar), local infection of the skin and subcutaneous tissue, Morbid Obesity(chronic disease in which a person has a body mass index of 40 or higher), Hypertension (high blood pressure), and Gastroparesis (delayed gastric emptying consisting of weak muscular contractions of the stomach). Record review of R #2's Minimum Data Set assessment dated [DATE] revealed R#2 had a BIMS score of 12 (Moderate Impairment), required supervision with eating (Oversight, encouragement, or cueing. Coding 1: Setup help only. Coding 0: Independent: no help or staff oversight at any time), limited supervision with personal hygiene, and extensive assistance with bed mobility, dressing, and toilet use. Record review of R #2's Care Plan dated 5/12/2023 revealed R#2 sustained blisters to lower abdomen, upper thigh and right groin while eating soup. Record Review of R #2's orders dated 5/12/2023 stated: burn to right groin, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%. Apply twice a day for 7 days. burn to right upper thigh, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1% twice a day for 7 days. Order Dated 5/25/2023 burn wound of the right lower lateral abdomen, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%, cover with ABD (abdominal) pad and dry dressing daily until resolved. burn wound of the right anterior upper thigh, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%, cover with ABD (abdominal) pad and dry dressing daily until resolved. Interview on 8/1/2023 at 2:18 pm with Dietary Manager revealed she was not working the day of the incident but was aware of the situation. Dietary Manager stated R#2 asked for soup in-between meals, which was rare and the dietary aide, took it upon herself to heat up the soup on the gas stove, put it in a bowl once heated, and served it to the resident. Dietary Manager stated there was no temperature record of what temperature the soup was at the time it was served to the resident. Dietary Manager stated, a dietary aide is not supposed to handle hot foods and should only be handling cold foods and dessert like foods. Dietary Manger stated on that day, dietary aide just thought she could heat up the food and serve the soup to R#2, not thinking it would cause an accident. Interview with R#2 on 8/1/2023 at 3:32 pm. revealed he was lying in bed and was sick with pneumonia on the day of the incident when R#2 asked staff for some chicken soup. R#2 stated someone brought him soup and did not ask for him to check to see if soup was hot. R#2 did state that the staff member told him it was hot, and to be careful, and staff member placed the soup on R#2's bedside table, and staff member walked out of room. R#2 then picked up bowl of soup and attempted to drink it while semi-sitting up in bed, when he spilled it on his abdomen, and leg area, causing him to burn himself. R#2 stated he had blisters on lower abdomen and groin/leg area, but they (staff) were taking care of his wounds. R#2 pulled down bed sheet to reveal area of injury. Resident stated he refused to go to hospital because he felt too ill to be moved around at that time. Observation of injury site on 8/1/2023 at 3:38 pm of R#2 revealed no noted blisters at that time but some redness to the skin. A cream-like substance was applied to lower right abdomen area as per orders. Interview with Dietary Aide on 8/2/2023 at 10:00 AM revealed a housekeeper came to her and told her R#2 wanted chicken soup because his stomach was hurting. Dietary Aide stated she took some soup and heated it up on the stove burner. Dietary Aide stated, she usually did not prepare hot foods and his was her first time to prepare hot foods. Dietary Aide stated she did not check the temperature of the chicken soup before giving it to R#2. Dietary Aide stated that the cook available that day was busy and was told to, just heat it up and was not aware she had to check the temperature prior to serving. Dietary Aide went to the R#2's room, told R#2 the soup was hot and put it on the bedside table and told R#2 to be careful, the soup is hot. Dietary Aide stated that when she left R#2's room, she heard R#2 yell out ouch. Dietary Aide stated an in-service was conducted and she now knows dietary aides are not supposed to heat up hot foods and she was just trying to help the R#2 by making soup and should not have done that (heat up food) but did not think it would result in an incident. Interview with DON on 8/1/2023 at 3:03 pm. revealed the incident occurred on the weekend and R#2 was not feeling well and requested soup from staff. DON stated, R#2 was a larger man and bedside table does not fit over him while he is in bed, so the bedside table stays to the side of the bed. DON stated, R#2 can eat on his own but just needs to have meals opened for him. DON stated in-services were conducted with kitchen staff to avoid further incidents in the future and is aware that Dietary Aides should not be preparing hot foods. MD and family were notified of incident. Interview with Administrator on 8/1/2023 at 3:10 pm revealed sometimes it was okay for the dietary aides to heat up foods but depends on what the food is. Administrator stated at the time of incident, it was ok for dietary aide to heat up the food as R#2 was requesting soup. Administrator was unable to describe the job role and duties of a Dietary Aide but did state, Dietary Aides are no longer allowed to heat up hot foods. Interview with wound care doctor on 8/16/2023 at 10:37pm revealed he was informed how the incident occurred and stated the injuries were consistent with a spill. Wound care doctor provides wound care to R #2 every week and initially, he would have described the wounds as being consistent with a second-degree burn (partial thickness burns that affect the outermost layer of the skin and extend to the middle skin layer below). Wound care doctor stated the wounds are almost healed and R #2 had responded remarkably well to treatment. Interview with Primary Physician on 8/16/2023 at 10:46am revealed he was aware of how the incident occurred and though R #2 denied going to the hospital, he ordered wound care to begin immediately, and R #2 has responded to wound care treatment well and wounds are almost healed. Primary Physician stated he did not officially diagnose the level of burn, but injuries were consistent with second-degree burns (partial thickness burns that affect the outermost layer of the skin and extend to the middle skin layer below). Interview with various staff members (different shifts) RN, Cook/Dietary Aide, LVN, CNA A, and CNA B, on 8/16/2023 revealed if a resident was to request hot foods like soup, they would check the orders to see if it is within their dietary limitations, and notify dietary staff of request. If staff were asked to heat up food, all staff stated they have a microwave in the breakroom used to heat up residents' food, they must check the temperature, so it does not exceed 165 degrees Fahrenheit and log the temperature down in the log book in the breakroom. Record review of in-services conducted on Food Service and Distribution dated 5/17/2023 which states; All reheated/precooked food should reach 165 degrees Fahrenheit for 15 seconds. Record review of in-service conducted on Food Temperature and Abuse and Neglect dated 5/12/2023 conducted by DON, Administrator and Dietary Manager. The following staff were verified to have received and understood the above trainings: RA A Dietary Aide Dietary Manager RN A LVN A CNA A Cook/Dietary Aide CNA B Record Review Dietary Aide Job Role revised on 6/1/2011 documented: Position summary: The overall purpose of the dietary aide position is to provide assistance in the delivery of dietary services. Incumbents may prepare and/or serve food items, set up tables and trays, wash tableware and cooking utensils, perform general cleaning tasks, and deliver soiled linin, etc. to the laundry. Essential Functions: Assures that sanitation and quality standards are met. Scrapes, stacks, loads, washes according to instructions, unloads and stores tableware and utensils. Sanitizes food cars and dishwashing counters after meal and keeps dishwashing area clean at all times. Logs/records wash/rinse temperatures. Neatly arranges tray and/or table setting with proper tableware, condiments, and tray card. Performs various food preparation tasks, and assists in apportioning servings. Prepares and serves beverages per menu/recipe. Cleans beverage dispensers according to manufacturer's instructions. Performs other cleaning tasks according to established schedules. Must be able to perform moderate to heavy lifting. Must be able to walk or stand for extended periods of time. May prepare and/or deliver nourishments/supplements identified with resident name room number date and time. May maintain or assist in maintain, dry storage areas by logging temperatures daily and handling the unpacking, dating, and rotating the food and non-food supplies. Identifies and corrects safety hazard. Performs other duties/tasks as may be assigned. Record Review of Food Preparation and Service Policy dated 7/2014 states; Food Service/Distribution 4. Prior to the point of service, the temperature of coffee or hot beverages will be checked to ensure temperature is 155 degrees Fahrenheit or below. If above 155 degrees Fahrenheit, ice will be added to the coffee or hot beverage until at or below 155 degrees Fahrenheit. On 08/17/23 at 4:08 pm, the Administrator was notified of a Past Non-Compliance Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator at this time.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one Resident (R#1) of six residents who were reviewed for falls, in that: 1.) R#1 fell to the shower room floor from a shower gurney and sustained injuries that required hospitalization while in preparation for bathing by one staff person when R#1 required the assistance of two persons. 2.) The facility had no system in place for inspecting shower gurneys on a routine basis or at least monthly as recommended in the Manufacturer's Manual. These deficient practices could affect residents at risk for falls by resulting in falls with injury or harm. Findings Included: Record review of R #1's Face Sheet dated 09/06/2019 reflected an admission date of [DATE]. The Face Sheet also reflected [DIAGNOSES REDACTED]., spinal stenosis, pain, unspecified. Record review of R #1's Fall Risk Assessment Form dated 10/23/19 revealed a score of 13 which meant she was at high risk for falls and a prevention protocol was warranted. Record review of R #1's care plan for fall interventions created on 07/03/2018 and updated on 10/23/19 reflected: Problem Start Date: 03/08/2015 I have the potential for falls, injuries, and side effects R/T (related to) use of [MEDICAL CONDITION] med's (medications) for DX (diagnoses) depression, anxiety and [MEDICAL CONDITION] disorder. Goal Target Date: 06/10/2015 I will be free from falls and complications R/T [MEDICAL CONDITION] med use through the next review date Approach Start Date: (Interventions) Administer medications as ordered; Monitor for potential side effects, notify MD (doctor) if observed; Monitor for changes in mood/behaviors, notify MD; Psych (psychiatric) F/U (follow up) as indicated; Monitor Q 3 MO (every 3 months) for possible reductions; Provide safe environment and encourage resident to use call light to call for assist; Notify MD and RP (responsible party) of any falls or injuries Record review of R #1's care plan for Activities of Daily Living (ADL) created on 03/08/15 and updated on 10/23/19 reflected: Problem Start Date 03/08/15 I have the potential for self-care deficits related to [DIAGNOSES REDACTED]. I require total assist with ADL needs. Resident requires assist of two staff for transfers and for mobility. Record review of R #1's Fall management Care Plan, signed by the DON and created on 11/14/19 after R #1's fall off the shower gurney reflected: Problem/Needs; Problem start date: 11/14/19; Category: Witnessed fall; Potential for falls and injuries r/t weakness and poor safety awareness; Date of actual fall: 11/14/19 fall with injury to forehead transferred to ER (emergency room ) Goals; Goal target date: 1/13/2020; Goal: free of falls or injury Interventions/Approaches: Date: 11/14/19; One on one staff in-service, use of shower bed for safety Disciplines: CNA and Nursing Record review of R #1's Physician order [REDACTED]. ADL (Activities of Daily Living) flow sheet: ROM (Range of Motion) daily with ADL'S-Twice a day; Use mechanical lift with 2 person assist for all transfers every shift. Medications flow sheet: [MEDICATION NAME] 9.5 mg for [MEDICAL CONDITION]; [MEDICATION NAME] tablet 15 mg once a day for [MEDICAL CONDITION]; [MEDICATION NAME] tablet 20 mg twice a day for heart failure; 2 [MEDICATION NAME] tablets 3 mg each at bedtime for [MEDICAL CONDITION]; [MEDICATION NAME] tablet 200 mg twice a day for lupus; Soma-Schedule IV tablet 150 mg at bedtime for muscle spasm; 1.5 [MEDICATION NAME] tablets 50 mg at bedtime for Major [MEDICAL CONDITION]; [MEDICATION NAME] ([MEDICATION NAME])- Schedule II patch 72 hour 100 mcg/hr, amount 1 patch every 72 hours (did not specify diagnosis); [MEDICATION NAME]-Schedule IV tablet 1 mg twice a day for generalized anxiety disorder; [MEDICATION NAME] tablet 12.5 mg once a day for [MEDICAL CONDITION]; [MEDICATION NAME] tablet 100 mg 1.5 at bedtime for Major [MEDICAL CONDITION]. Record review of R #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected the following: R #1's mental status was moderately impaired. R #1 was totally dependent on staff for bathing, bed mobility and for transferring and required the assistance of two people for each of these tasks. Record review of Incident/Accident Report dated 11/14/19 for R #1 reflected: Fall in shower room. Current mobility: W/C (wheelchair)-Staff Assist and Transfer-Staff Assist. Medical History: Fall History Mental Status: Alert and Oriented x 3. Resident was in shower bed when resident was turned to facilitate removal of clothes, resident fell off shower bed onto floor. Assessed head to toe, noted laceration to forehead, ice applied to stop bleeding, EMS (emergency medical services) called for transfer to nearest hospital. Physician notified by phone at 9:30 a.m. Responsible Party notified by phone at 9:30 a.m. Actions to minimize reoccurrence: One on one in-service of staff. Record review of R #1's Investigation Follow-Up dated 11/14/19 reflected: Description of Situation: Resident rolled out of shower bed onto floor; injury noted to forehead, small laceration. Summary of Investigation: When resident was turned on shower bed she fell off onto floor. Past Intervention Attempted: NA (Not Applicable). Recommendations/New Interventions: One on One InService; Transfer to (name) ER (emergency room ). Notification Summary: Family notified 11/14/19 at 0930; Physician notified 11/14/19 at 0930. Record review of R #1's Physician's Telephone Orders dated 11/14/19 reflected: Transfer to nearest ER via 911 EMS due to fall and injury. Record review of R #1's Patient Transfer Form dated 11/14/19 reflected: Date of transfer: 11/14/19. Transferring to (local hospital). Record review of R #1's SBAR Communication Form and Progress Note for RN's/LPN/LVN's dated 11/14/19 reflected: Situation: Witness fall. Skin Evaluation: Laceration to forehead and back of head. Pain Evaluation: Does the resident have pain? Yes. Description/location of pain: Head. Does the resident show non-verbal signs of pain: Yes, grimacing. Appearance: Describe observations: Resident rolled out of shower bed when turned, onto floor, causing lacerations to forehead and back of head. Review and Notify: Primary Care Clinician Notified: (name of physician) Date: 11/14/19 at 0930. Recommendations of Primary Clinicians: Transfer to nearest E.R. for evaluation via 911 EMS. An observation of R#1 on 11/19/19 at 3:40 PM at a local hospital revealed R #1 wearing an Aspen Cervical Collar. R #1 had a black scab to top of her forehead, midline. Further observation of R #1 revealed she was wearing a back brace and soft casts below both of her knees. An attempt to interview R#1 on 11/19/19 at 3:40 PM revealed she was feeling sore all of over. R#1 was not able to clearly explain how she had fallen off the shower gurney on 11/14/19. An interview on 11/19/19 at 3:55 PM with R#1's family member who was visiting with R#1 in her hospital room said R #1 had 2 cervical fractures and a lumbar fracture. During an interview on 11/19/19 at 11:50 AM CNA [NAME] who was with R #1 when she fell , said that CNA F helped transfer R #1 from the bed to shower bed using a mechanical lift. CNA [NAME] said CNA F did not help her bathe R #1 because CNA F had to answer call lights. CNA [NAME] said R #1 was totally dependent on staff for care. CNA [NAME] said she had put in place the necessary pins on the side rails of the shower bed and said she felt that maybe the pins were not holding very well because of constant use. CNA [NAME] said R #1 was holding onto the side of the shower bed rail while she removed R #1's brief and clothes. CNA [NAME] said, When I saw the resident was falling I tried to grab her leg but it all happened so fast I couldn't catch her from falling. CNA [NAME] said she yelled out for help and LVN G, LVN A, and the Nurse Practitioner (NP) came to help. CNA [NAME] said, years back it was always two people to give showers then for some reason the charge nurses said it was only one person to give showers and one person should stay on the floor to answer lights. In an interview on 11/20/19 at 11:56 a.m. with CNA F, she said (on 11/14/19) she helped CNA [NAME] transfer R #1 using a Hoyer lift, from the bed to the shower bed, then helped her to the shower room. CNA F said she was not there when the fall happened to R #1. CNA F said she helped CNA [NAME] wheel R #1 into the shower room and then she went to the hall to answer call lights that were going off and to get other residents up for therapy. CNA F said they had not been using two CNAs to shower residents because one CNA had to be on the hall. CNA F said the nurses knew there was just one CNA showering residents on shower beds. In an interview on 11/20/19 at 12:15 p.m. the facility treatment nurse LVN A said on 11/14/19 she heard CNA [NAME] call out to another nurse to the shower room. LVN A said since she was closer she ran into the shower room and found R #1 on the floor laying on her back. She said she saw blood underneath R #1's head. She said by this time LVN G had gotten there, so LVN A went to call 911, then NP went into the shower room and began to apply pressure to R #1's head. LVN A said R #1 was talking and wanted to get up and that R #1 still had her bra and shirt on her left side. LVN A said R #1 never told her what happened. In an interview on 11/20/19 at 12:40 p.m., LVN G, said she was in the middle of the hall on 11/14/19 passing medications when CNA [NAME] opened the shower room door and yelled out for LVN [NAME] She said LVN A went to see what was happening too. LVN G said she saw R #1 on the floor. She asked CNA [NAME] what happened. CNA [NAME] told LVN G that when she turned R #1, the pin holding the shower bed rail up came off and R #1 fell . CNA [NAME] said she saw a gash on R #1's forehead and blood from back of her head. LVN G said the NP (Nurse Practioner) went in too and she slipped a towel under R #1's head. LVN G said CNA [NAME] was showering R #1 by herself. LVN G said, we always did two-person showers and two-person transfers- don't know when it happened, but it changed. LVN G went on But now it's changed to two to transfer and two to shower as of the day of the incident with R #1. LVN G said after the incident they did not let the CNA's use shower beds that day at all. In an interview on 11/26/19 at 4:33 p.m. the DON said R #1's Minimum Data Set (MDS) reflected she required two persons for bathing. When asked why two CNAs were not used to bathe R #1 on 11/14/19 the DON said, whatever we have in place now is what has to be followed. The DON stated that following all resident's MDS and care plan was important for the resident's safety. When asked what interventions to keep R #1 safe from injury due to falls were on R #1's 10/23/19 care plan, the DON said after a long pause I don't know what to say (about the care plan). In an interview on 11/26/19 at 4:45 p.m. LVN B, MDS Coordinator, when asked what actual intervention was on the care plan to keep R #1 safe from injury due to fall the MDS Coordinator said, she (R#1) never had a fall before in the shower. When asked how would you provide a safe environment? which is what is listed on (R #1's) care plan as an intervention, the MDS Coordinator said, she could not transfer. The MDS coordinator acknowledged that R #1 required two persons to assist with transfers and mobility and she required two persons for bathing as she was totally dependent on staff. The MDS coordinator said, since this company (name of company) took over, now recently only one staff was used in the shower. She said they had been using only one staff in the shower for the last year and a half. In an interview on 11/26/19 at 11:26 a.m., when asked for a policy (P&P) on shower gurney use prior to R #1's fall, the DON said she looked and could not find a P&P prior to R #1's fall on 11/14/19. The DON said that to her knowledge there was no Shower Gurney P&P at the time of R #1's incident. She said they now have (since R #1's fall) the Shower Gurney and Proficiency Check. The DON said she had never seen nor read the manufacturer's recommendations/instructions for shower gurney use. The DON said the facility Quality Assurance (QA) committee had not met yet regarding the incident with R #1. She said it will be presented to the committee physician on the third Wednesday of (MONTH) 2019 or when the physician is available. Record review of the Shower Gurney Procedures and Proficiency Check revealed: 1. Check all pins, bars and other apparatus on the shower gurney to ensure that no pins are missing, and there are no cracks in PVC piping. If you discover any problems with the shower gurney DO NOT USE it and report the problem to the administrator immediately. 2. Ensure that the brakes to the shower gurney are locked. With two people always, roll the Hoyer lift under the shower gurney with the side bar to the shower gurney in the down position on the Hoyer lift side, positioning the resident over the center of the shower gurney. 3. Guide the resident gently down onto the shower gurney, supporting the resident manually until the Hoyer lift can be unhooked from the sling and removed out from under the gurney. 4. Secure the side rail. Make sure any pins/clamps are in place securely. 5. Two people assist with the transporting of residents down the hall and into the shower room, AND AT ALL TIMES WHEN ANY CARE IS PERFORMED ON THE SHOWER GURNEY (THIS INCLUDES DRESSING, TURNING, ETC.) In an interview on 11/26/19 at 9:00 a.m. the facility Central Supply clerk was asked for manufacturer's recommendations for shower gurneys. She said she would look for the document. In an interview on 11/26/19 at 1:58 p.m. the Central Supply CNA said the corporate office had faxed over the manufacturer's recommendations for the shower gurneys to her on the morning of 11/26/19 after the surveyor had asked for it. Central Supply CNA said she had never read the manufacturer's recommendations for the shower gurneys. She said she had put in an order for [REDACTED]. When asked about the incident with R #1, Central Supply CNA said she thought the screws were not good on the bed and the resident had fallen off the bed. She said they did not use that shower bed after R #1's fall. In a telephone interview on 11/27/19 at 8:35 a.m. the facility Regional Director, when asked if he had read the manufacturer's recommendations for shower gurneys, said he relied on facilities to do that and that every single piece of equipment comes with instructions and he doesn't have time to read them all. Record review of the undated manufacturer's recommendations tittled (medical equipment company name) PVC Healthcare, Environmental & Foodservice Devices Owner's Manual revealed the following information: Refer to This Manual Before Using These Devices: Healthcare: · (Company) Shower Chairs · (Company) Reclining Shower Chairs · (Company) Manual Shower Beds Introduction: In this owner's manual, you'll find important information you should read before assembling or using this product. Please keep this manual in a safe place for future reference . General · Read and follow all directions and warnings before using this device. Do not operate this device without first reading and understanding the contents of this manual. Death or injury may result from the improper use of this device or failure to follow all directions and warnings. · Check to ensure the device is properly assembled before use and after making any adjustments, repairs or service to the device. · Care & Maintenance PVC Piping and Casters · Wipe down piping with nonabrasive cleaner- DO NOT use solvents · If casters are used in wet environment, keep lubricated with white [MEDICATION NAME] paste or similar lubricant · Periodically remove hair and other buildup from casters · Check pipe and fittings for cracking, fractures or other damage at least monthly-call your distributor if any damage is discovered · At least monthly, check all glued fittings by attempting to pull PVC out of the fittings- call your distributor if any loosening is discovered In an interview on 11/26/19 at 11:30 a.m. after looking through the facility policy book the DON said the undated document titled Fall Risk Assessment Policy was their current Fall P&P. She pulled out another Nursing Policy and Procedure with the Subject Falls-Evaluation and Prevention dated 03/2012 but she said this was old policy that they had left over from the last company that owned the facility. She said at the time of R #1's fall the document titled Fall Risk Assessment Policy was the one they were using along with the Fall Risk Assessment Form. Record review of the facility undated Fall Risk Assessment Policy revealed the following: The facility will do a Falls Risk Assessment upon admission of each new resident. The Assessment will be repeated quarterly during the MDS review and when a significant change has occurred in the residents' condition. This form will be kept with the care plans and will be discussed at each care plan meeting. Facility documentation will reflect all attempts made by the facility to assess and reduce the risk of falling for the residents. Fall Risk Assessment Procedure: Purpose: 1. To assess the resident's status upon admission, quarterly, and with any significant change. 2. To develop prevention protocol if resident is considered high risk. Documentation: 1. If resident has a total score of 10 or greater, the resident should be considered high risk for potential falls. 2. A prevention protocol (care plan interventions) should be initiated immediately and documented on the care plan. In an interview on 11/20/19 at 11:20 a.m. the assistant maintenance director said they did not document inspections of medical equipment on a log, or at least he did not. He said the Maintenance Director might. The assistant maintenance director said he had taken part (11/14/19 -11/18/19) in providing shower gurney in-services to all the CNAs one to one to make sure the pins were latching right and to make sure the brakes were locked. In an interview on 11/20/19 at 11:45 a.m., ADON said she had done one on one in-services with CNAs regarding shower bed procedures after R #1's fall on 11/14/19. ADON said the in-service consisted of explaining procedures to the CNAs regarding resident showers such as having two persons, making sure wheels locked, no cracks in the PVC. ADON said two CNAs were required when rolling residents in shower beds down the hall with one CNA on each side. In the shower two CNAs were required to help turn when bathing for all residents who use the shower bed and two CNAs when returning the resident back to the room. ADON said these procedures started after R #1's incident on 11/14/19. ADON said unit managers, the staff coordinator and other ADON's all participated in providing in-services. In an interview on 11/26/19 at 3:40 p.m. the DON said the CNAs and the nurses had been in serviced 11/14/19 through 11/18/19 on properly securing shower beds. DON went on to say that from 11/20/19 to 11/21/19 CNAs and nurses were in-serviced on ensuring that ADL-care plans were being followed. She provided copies of sign in sheets. She also said that all CNAs were given proficiency checks after being in-serviced regarding shower beds. DON said these in-services and proficiency checks were done from 11/14/19 to 11/18/19. In an interview on 11/26/19 at 4:08 p.m. the DON said the Shower Gurney Procedures and Proficiency Check document was received from Corporate office on 11/14/19 after Res #1 incident. The DON stated that requiring two CNAs for residents who use a shower gurney started on 11/14/19 after R #1's incident/ accident/ fall. Record review of IN-SERVICE TRAINING REPORT signed by CNA [NAME] on 11/14/19 reflected: Topic: Abuse and Neglect/ Shower Beds Contents or summary of training session: Abuse or neglect must be reported to the abuse coordinator immediately. Do not wait for someone else to report it. It is your responsibility to protect the residents of this facility. If you do not report abuse or neglect, you are just as guilty as the person who did it. If you are unsure about whether it was a case of abuse or neglect - report it anyway! Protect our residents! Report to Your Abuse Prevention Coordinator: (Name of Coordinator) (the administrator) (phone number). If at any time, you cannot reach your Abuse Prevention Coordinator - you call (name) (DON). C.N.[NAME]'s are to ensure shower beds are safely secured with pins at all times. Any questions or concerns for shower bed safety, DO NOT USE . Report to maintenance immediately! After resident has been transferred into shower bed, both C.N.[NAME]'s must verify shower bed (has) been locked safely and securely. Any residents requiring use of shower bed for bathing/showering must have two C.N.[NAME]'s present during bath/shower at all times. Demonstration for shower bed safety has been provided and understood. In an interview on 11/20/19 at 11:35 a.m. the Maintenance Director said the facility had implemented on 11/14/19 a procedure to do monthly equipment checks to include shower gurneys. He said prior to this they had no procedure for routine equipment checks they would service equipment only after being notified by staff that equipment needed repairs. In an observation and interview on 11/20/19 at 12:30 p.m. the Maintenance Director said they had removed and taken the shower bed that had been used with R #1 out of commission on 11/14/19. Surveyor observed the shower bed that had been taken out of commission and where it was stored on the second floor. Observation of the shower bed did not reveal any noticeable defects. The maintenance director said he had replaced the shower bed with a new one immediately. In an interview on 11/26/19 at 9:07 a.m. the Executive Account Manager with the medical equipment company that sold shower gurneys, said the facility had purchased shower gurneys on 7/12/19, 7/28/19 and on 11/14/19. He provided serial numbers for each shower gurney sold to the facility. In a later call on 11/26/19 at 10:14 a.m. the Executive Account Manager said the shower gurney involved in R #1's incident was the one purchased on 7/12/19. He said his company started an investigation based on pictures provided by the facility and the investigation was pending more pictures. In an interview on 11/26/19 at 10:30 a.m. the Maintenance Director provided the serial number of the shower gurney that the facility had taken out of commission because of R #1's fall on 11/14/19. He also clarified and provided his notes that said, created inspection for all shower beds on 11/15/19; tagged with red dots with initials. In a telephone interview on 11/27/19 at 8:09 a.m. the facility Regional Director said he had no definitive information on what had happened on 11/14/19 with R #1 and the shower gurney. He said his gut feeling was that the CNA probably forgot to put all the pins in to keep the rails from falling. He said since the incident with R #1 he had been working with the medical supply company to try to find out what may have happened. He said he took pictures of the shower gurney in question to send over to the medical supply company. He said they (the facility) don't want a repeat of what happened to R #1. When asked if all three pins were out when the resident fell off the gurney he said he did not know if all three pins were out; that they were too busy taking care of the resident. He said he wanted to keep the shower gurney out of commission until they knew what happened. The Regional Director said that prior to R #1's fall, typically, unless they were combative one person was used when a shower gurney was used to bathe residents. He said he then realized (after R #1's fall) that when you go to turn somebody the PVC pipe is not going to hold the resident. He said whether this was a mechanical problem or not, all the buildings that he oversees now use two people when showering residents who require a shower gurney. He said he wrote the Shower Gurney Procedures and Proficiency Check document that they are now using since the incident on 11/14/19 with R #1. In an interview on 11/27/19 at 9:57 a.m. the DON agreed that R #1 was at high risk for falls and stated that R #1's care plan should have reflected interventions to keep her safe from injury due to falls. She stated the facility will start an audit of all resident care plans to ensure that they are including fall prevention interventions.

Based on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of one Resident (R#432) of 27 residents reviewed for quality of care. The Administrator failed to implement policies and procedures for Quality of Care and Pharmaceutical Services. The Administrator did not ensure that nursing staff followed facility protocols regarding reviewing new admissions; protocols for insulin administration and monitoring; and administration of medications per physician's orders [REDACTED]. The Director of Nurses (DON) failed to implement policies and procedures for Quality of Care and Pharmaceutical Services by ensuring supervising nurses reviewed admission documentation for thoroughness and accuracy; that nursing staff were trained on protocols regarding diabetic monitoring and documentation of administration of diabetic medications; and that nursing staff demonstrated knowledge of when to contact the physician if medication and treatment orders required clarification. The above failures resulted in an IJ situation on 07/18/18. While the IJ was removed on 07/21/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place 44 residents with [DIAGNOSES REDACTED]. The findings were: In an interview at 11:30 a.m. on 07/17/18, the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) DE fed R#432 lunch on 07/16/18, and R#432's Family Member (FM) picked him up around 2:00 p.m. on 07/17/18. The DON said R#432's FM called her on 07/16/18, and said that she took R#432 to the hospital after picking hiim up at the facility and he was admitted to ICU with a blood sugar of 952. The DON said she reviewed R#432's chart and found that there were no treatment records. The DON pointed at R#432's admitting physician's orders [REDACTED].#432 and no orders for doing finger sticks. The DON said she suspended the admitting nurse because she did not transcribe the insulin order to the diabetic or finger stick MARS (Medication Administration Records). The DON said, What we have is a multi-system failure here. The DON said she had only been at the facility a few days, with a start date of 07/11/18, and she was just starting to look at the processes and concerns of the facility and was not aware of any concerns regarding R#432 until she received a call from his FM on 07/16/18. The DON said the processes for admissions had not been followed. The DON said charts were not reviewed in the morning meeting the day after R#432's admission, and they should have been reviewed. The DON said she reviewed new admissions daily. The DON said the facility began reviewing any residents who had codes for diabetes (on their Minimum Data Set) and reviewed their medication cart-to-MAR-to-Physician order [REDACTED].#432 was a new resident. The DON said the admitting nurse should have called and gotten an order from the physician for finger sticks. In the interview at 11:30 a.m. on 07/17/18, surveyor asked the DON what the complications of missing 14 insulin doses, the number of doses of insulin missed by R#432, would be; the DON responded that the resident could go into a coma, die or have a [MEDICAL CONDITION], and said It's a big danger. When asked what Policies and Procedures (P and P's) were in place regarding admissions and treatments, the DON responded that she did not know since she had been at the facility such a short time and had not gotten involved with the P and P's yet. In the interview at 11:30 a.m. on 07/17/18, the DON said the nurse who discharged R#432 discharged him with an insulin vial that expired in (MONTH) (YEAR). The LVN who discharged him, the DON said, did not seem to think anything of that. In an interview at 2:03 p.m. on 07/17/18, R#432's FM said she was R#432's caregiver and he lived with her. FM said R#432 had two [MEDICAL CONDITION] and a [MEDICAL CONDITION] in (YEAR). FM said R#432 was able to talk to her a little bit but had dementia and could not talk very much. R#432 was paralyzed on his left side and used a wheelchair; FM said R#432 needed help to eat, his food was a chopped texture and his drinks were nectar thick. FM said R#432's blood sugars ran 180 or 190. FM said she gave R#432 his morning insulin injection on 07/09/18 before she took him to the facility and thought his blood sugar was 160 at that time. FM said she checked R#432's blood sugar three times a day; before breakfast, before lunch and before dinner. R#432 said the Veterans Administration allowed respite care for R#432 for up to 30 days a year. FM said she and her family went out of town while R#432 was at the facility. FM said R#432 had been to the facility for respite three or four times and this stay from 07/09/18 to 07/16/18 completed his 30 days of respite that he was allowed for the year. FM said R#432 was a very good eater. In the interview at 2:03 p.m. on 07/17/18, FM said she gave R#432's medication to the facility when he was admitted . FM said R#432 had a mood disorder medication, Tamsulosin for his prostate; two vitamins in the morning; a heart pill twice daily; and insulin. FM said she took a brand-new bottle of insulin to the facility and it was not touched during his stayed there that she could tell. FM said the VA sent R#432 a new bottle of insulin about a month and a half ago. FM said she had removed the cap from the bottle of insulin. FM said the facility called her on Friday, 7/13/18, to come pick up R#432, but she said that the respite care was supposed to last until 07/16/18, and the facility agreed to keep him there until 07/16/18. In the interview at 2:03 p.m. on 07/17/18, FM said she called and spoke to LVN AS on 07/16/18 to see how R#432 was doing. LVN AS said R#432 was doing good, sitting at the nurse's station. FM said she told LVN AS that she would be at the facility shortly to pick R#432 up. FM said that when she went to pick up R#432 about 2:00 p.m. on 07/16/18, she found R#432 in his room. FM said R#432's eyes were sunken in and he looked ten pounds lighter. FM said she went to the nurse's station and asked how R#432 had been eating, and said that R#432 looked sick, eyes sunken in and he looked skinny. LVN AS was not there as she was getting his medication. The people at the nurse's station said R#432 was eating 75% of his food and was on nectar liquids. FM said she signed R#432's discharge papers and after taking him out of the facility, she decided to take R#432 to the emergency room . FM said R#432's tongue was sticking out and he was not able to respond. R#432's arms were shaking and when she asked if he was ok, he gave no response. FM said after waiting one and one-half hours at the emergency room (ER), R#432 was taken back to a room and blood work was initiated. FM said about 5:30 p.m. on 07/16/18, she was told R#432 had high blood sugar that was so high their monitor could not read it. The ER later determined R#432's blood sugar was 952 and his sodium level was 169. FM said she called the facility and spoke to the DON on 07/16/18 to find out what was going on with R#432 and about 6:00 p.m. or 6:30 p.m., she was told the facility never gave R#432 his insulin. FM said in the morning of 07/17/18, she received a call from an ICU nurse that R#432 was severely dehydrated and had three open sores on his bottom. FM said she told the Administrator that R#432 went in with a pressure ulcer on his left heel that was in the process of healing and he did not have pressure ulcers on his bottom. FM said when she picked up R#432 from the facility, the pressure ulcer on his left heel was open and draining. FM said R#432's blood sugar had been responding to his care at the hospital and was 191 about an hour ago. FM said R#432 was still hallucinating and very confused. FM said she was angry because the facility never notified her of any problems with R#432's insulin, and he was also crying because the ulcers on his bottom were hurting him. FM said, I left him there so that they could take care of him and I came home, and he was dying. FM said R#432 raised her and she has been taking care of him since (YEAR). In an interview at 3:06 p.m. on 07/17/18, LVN P said she did not remember anything regarding medication administration for R#432. LVN P said R#432 was alert, up in a wheelchair with assistance, and needed total care. LVN P said she did not remember whether R#432 required finger sticks or insulin and said it would help if she could look at the finger stick book. LVN P said if R#432 was no longer at the facility, insulin that was given would only be documented in the finger stick book. LVN P said the handwritten MAR-finger stick book was on the medication cart. LVN P reviewed R#432's startup orders, which had medications listed and initials for medications that were administered. LVN P said she recognized her signature on the start up orders and said she did not recall seeing an order for [REDACTED]. LVN P said if she had seen the order for insulin, she would have written it to put in the finger stick book and would have put it in the finger stick book. When asked what a nurse should do if there were no orders for checking blood sugars for an insulin dependent diabetic, LVN P answered that they were supposed to have finger sticks so that blood sugars could be tracked. LVN P said she did not see orders for finger sticks on R#432's start up orders. LVN P said it was everyone who took care of R#432's responsibility to follow up on insulin/finger stick orders. In the interview at 3:06 p.m. on 07/17/18, LVN P said the admitting nurse would write all medications down on the start up orders and then complete the Diabetic Flow Sheet and put it in the diabetic book. LVN P said the insulin column on the start up orders was blank; she said she would wonder if it was ever given and would call the doctor. LVN P said finger sticks and insulin were never documented on the startup MAR and were always documented on the diabetic book. In an interview at 3:41 p.m. on 07/17/18, the DON said she looked through the finger stick/diabetic book twice after she was called by R#432's FM, and she did not find anything regarding R#432's finger sticks/insulin. The DON confirmed R #432 did not have oders for blood glucose monitoring. The DON said the nurses, any nurse involved with R #432's care, should have identified that there were no fingerstick orders and should have called the physician to get orders since R #432 was a diabetic and was prescribed daily insulin administration. The DON stated the importance of fingersticks was to monitor and track the residents blood glucose levels and evaluate whether his prescribed insulin was effective. The DON said if the blood glucose level was not known, administration of the prescribed insulin could cause [DIAGNOSES REDACTED] (low blood sugar) placing the resident at risk for coma and/or death. The DON further explained that if the blood glucose level was not known, the resident's blood sugar to be too high and potentially cause coma or death. In an interview at 4:47 p.m. on 07/17/18, LVN A said she admitted R#432 on 07/09/18. LVN A said she had three days of orientation and the orientation did not include the admission process. LVN A said it was only the second admission she had done, and she asked LVN AS and RN/ADON AK to review the admission for R#432 because she wanted to be sure it was done correctly. LVN A said the next day she asked RN/ADON AK if she had completed R#432's admission correctly, and RN/ADON AK responded that she had not reviewed it but from what she knew it was done okay and she would look at it. LVN A said she did a head to toe assessment of R#432, looked at his medications from home and compared them to what the physician ordered. LVN A said the medications brought in by R#432's FM were in a little box; she said insulin was in the little box and was written on the startup orders. LVN A said the medications were already written out by LVN AS on R#432's start up orders when she proceeded with his admission, and R#432 had already arrived at the facility. LVN A said she reviewed the medications with the Nurse Practitioner who oversaw R#432's care at the facility, and she crossed out four medications and wrote error because they were no longer being ordered. In the interview on 07/17/18 at 4:47 p.m., LVN A said she was a relief worker and did not know the facility procedure of transcribing insulin and finger stick orders to the Diabetic MAR and putting it in the diabetic book. LVN A said she did not notice that there was no order for finger sticks for R#432 but she knew as a nurse that they should have been done. In an interview at 5:08 p.m. on 07/17/18, LVN R said she worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she remembered R#432 and said, He's diabetic. I checked his sugar when he was here before. He was here for respite. I saw insulin in the med cart. There was no paper for him in the diabetic book, so I thought, Okay, I guess we don't check his sugar. Why did they bring his insulin? LVN R said there were things marked out on the MAR and she did not see any time on the startup orders for insulin to be given. LVN R said, A lot of us missed it. Where's the sheet? All diabetic stuff goes on one sheet. LVN R said she told LVN AS, who worked 7:00 a.m. to 3:00 p.m., that she was wondering why they were not checking his sugar. LVN R said LVN AS said she wondered the same thing. Surveyor asked LVN R if she called R#432's physician to clarify whether insulin should be given to him, and she replied she did not call the physician because he could not practice any longer. Surveyor asked if she notified her supervisor that there were concerns regarding R#432's insulin administration, and she replied that she answered to RN/ADON AK and she did not inform RN/ADON AK. LVN R said she overlooked doing that. LVN R said she should have notified someone. LVN R said they also missed administering R#432's Vitamins with minerals. When asked what the possible consequences were of not giving insulin to a diabetic when it was ordered, LVN R responded that the resident could go into a coma, go to the hospital or die from it. In an interview at 5:22 p.m. on 07/17/18, LVN CB said he worked at the facility since the end of (MONTH) (YEAR). LVN CB said R#432's orders were never transcribed to his MAR. LVN CB said R#432's startup orders were confusing to pass medications, with marks through some of the medications and other things changed. LVN CB said the insulin and minerals were at the bottom of the start up orders. He said they should have put the hours for the insulin to be given in the column next to the medication. LVN CB said insulin should have been given at 7:00 in the morning and the minerals should have been given daily. LVN CB said no doses of insulin were given and normally there should be an insulin flow sheet, but R#432 did not have anything in the diabetic flow book. LVN CB said R#432 did not have insulin in the med cart. The insulin was expired, he said, and was usually in the top middle drawer in the cart, but instead it was put in the refrigerator. LVN CB said the third shift stocked the med carts. LVN CB said RN/ADON AK said R#42's insulin was in the refrigerator. LVN CB said the insulin was not in the cart as he would have noticed it. LVN CB said he did not know R#432 was diabetic. LVN CB said the diabetic book was part of his orientation and all halls had them. In an interview at 5:45 p.m. on 07/17/18, LVN CR said she worked at the facility since (MONTH) 5, (YEAR). LVN CR said she was oriented on the use of the diabetic book. LVN CR said she assisted R#432 with eating lunch on 07/16/18, just before his FM picked him up from the facility. LVN CR said R#432 tolerated the meal well; when she moved him back in his wheelchair because he was sitting forward, LVN CR made a sighing sound when she moved him back. LVN CR said R#432 ate his food, drank juice, water and milk, and tried to grab liquids. LVN CR said liquids fell out of R#432's mouth as he drank. LVN CR said R#432 drank thickened liquids but she did not remember the texture of his food; he ate more than 80% of his meal, she said. LVN CR said she had no awareness R#432 was on insulin and she never administered medications to him. In an interview at 7:15 p.m. on 07/17/18, LVN A said she kept notes of everything she did during the day at work. She said she remembered that she did not find any insulin in R#432's box of medications that his FM brought from home. LVN A said she remembered that insulin as written on the MAR and she verified these orders with R#432's physician. LVN A said other shifts would have written on the MAR and would have seen it. In an interview at 7:23 p.m. on 07/17/18, RN/ADON AK said she remembered R#432 from previous admissions. RN/ADON AK said after she found out R#432 never received insulin, she noted that the insulin was written near the bottom of the start up orders and was supposed to be transcribed to the diabetic MAR, but it never made it on there. RN/ADON AK said LVN A checked in R#432's medications and she was the admitting nurse. RN/ADON AK said she was notified by LVN AS after she discharged R#432 that she found a vial of insulin and it was expired and it was from (MONTH) (YEAR); that was when everything came to light at the end of the day on 07/16/18. Upon discharge on 07/16/18, RN/ADON AK said she stumbled upon an expired insulin vial in the refrigerator of the med room and she gave it back to FM. RN/ADON AK said she did not know how the insulin ended up in the refrigerator. RN/ADON AK said when a new resident was admitted , she checked the MARS for discrepancies. When asked if she reviewed R#432's MARS for discrepancies, RN/ADON AK said she skimmed over it but did not check the MAR and see that it was transcribed to the diabetic MAR. RN/ADON AK said it looked like a standard admission. RN/ADON AK said she saw that R#432 had insulin listed at the bottom of the start up orders. RN/ADON AK said LVN A had over three days of orientation on the floor, including shadowing another nurse. RN/ADON AK said LVN A had knowledge of the diabetic book, but she got overwhelmed and she forgot a step. RN/ADON AK said no one said they knew who put the insulin in the refrigerator. RN/ADON AK said it was not that unusual that orders were received for giving insulin without doing finger sticks as some physicians did not order accuchecks of blood sugar. RN/ADON AK said she would have expected her 7:00 a.m. to 3:00 p.m. nurses or her night shift to catch that the insulin was not transcribed to the diabetic MAR, and she said she expected more from herself. In an interview at 7:48 p.m. on 07/17/18, LVN A said she verified R#432's orders with a Nurse Practitioner (NP). Regarding the insulin, R#432 was supposed to be given 15 units in the morning and seven units in the evening. LVN A said she would have written in the nurse's notes if she had verified whether the NP wanted finger sticks to be done. LVN A said there was no Policies and Procedures book to look through to see if she did the admission correctly. LVN A said she could not remember if she administered any insulin to R#432. LVN A said she worked for the corporation that owned the facility ten to [AGE] years ago, and did not remember a procedure for a diabetic book. In an interview at 8:11 p.m. on 07/17/18, FM said R#432's blood sugar was at 150 but he was still dehydrated and in ICU at the hospital. FM said she was sure she gave the facility a whole new bottle of insulin when she took R#432 to the facility on [DATE], but she did remember removing the cap. FM said she would check the expiration date of the insulin. In an interview at 9:00 p.m. on 07/17/18, FM said the insulin she took to the facility on [DATE] was filled on 02/14/18 and had an expiration date of 01/2020. The insulin also said to discard the bottle after 02/13/19. FM said she gave the medications to LVN AS (calling her by her first name and describing her) when she took R#432 to the facility on [DATE]. FM said when she picked up R#432 on 07/16/18, she noticed that the outside of the box of insulin was written in black marker, 03-17-18. FM said R#432's blood sugar was now down to 115 and his labs were looking good, and the hospital was going to see if he would eat a little bit. In an interview at 9:58 a.m. on 07/18/18, LVN AS said she worked the 7:00 a.m. to 3:00 p.m. shift. LVN AS said she received R#432 alert on the day he came into the facility. LVN AS said she wrote the headers and footers of the admission packets and wrote down his medications but did not write down the times he took them. LVN AS said R#432 got to the facility at 2:45 p.m., and because she got off work at 3:00 p.m., she did not do the admission. LVN AS said she gave the incoming nurse, LVN A, report, and R#432 and FM went straight into the Social Worker's office. LVN AS said on the morning that R#432 was discharged , 07/16/18, LVN R gave her report and told her R#432's insulin was expired and did not need to be on the cart. The date that it was expired was written in black on the side of the insulin box; she looked at the box and it was opened in (MONTH) and did not have an expiration date. LVN AS said she knew it was only good for 28 days. She put it in the refrigerator around 7:00 a.m. When R#432 left, she put all of R#432's medications in a bag and gave them to his FM. In the interview at 9:58 a.m. on 07/18/18, LVN AS said she passed medications to R#432 on 07/09/18, 07/10/18, 07/11/18, 07/15/18 and 07/16/18. She said she passed medications to R#432 when he was at the facility before this respite stay, and she now remembered he took insulin before. LVN AS said she probably did see that R#432 had insulin written on the start up orders, and the list of medications came from a fax the facility received from the Veterans Administration with R#432's [DIAGNOSES REDACTED]. LVN AS said she remembered R#432 was supposed to be given insulin around 9:00 p.m. LVN AS said LVN A was new at the facility. LVN AS said if it was her admission, she would have rewritten the start up orders and put an asterisk on them and would have put the insulin on the insulin sheet. The start up orders would have been faxed to the pharmacy. LVN AS said she did not tell LVN A to transcribe to the insulin record. It was automatic, LVN AS said, for RN/ADON AK to review and tell her what need to be corrected on admissions. LVN AS said a resident could die if he missed his insulin for a week. In an interview at 10:30 a.m. on 07/18/18, the DON said she was in the process of ensuring everyone who handled admissions knew the policies and procedures for them. The DON said she did not know who put the black marker with the date 03-17-18 on R#432's insulin. In an interview on 07/20/18 at 11:00 a.m., LVN R said she got report on 07/09/18 from LVN A. LVN R worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she said she knew she needed to check R#432's blood sugar and said there should have been orders for accuchecks, saying, Yes, absolutely, no doubt about it. In an interview on 07/20/18 at 5:26 p.m., LVN A said that she looked at some notes that she kept at home regarding medications that she gave during her shifts, and she found that she had given seven units of insulin to R#432 once or twice when he was at the facility. She said she also remembered checking his blood sugar once or twice before giving him his insulin. She said she found the insulin in the top drawer of the medication cart. After that, she said she was on vacation. In an interview at 10:55 a.m. on 07/21/18, the DON said each nurse was responsible for ensuring the medications were correct. The DON said it was not the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure the insulin was not expired. In an interview and record review at 12:10 p.m. on 07/21/18, surveyor and LVN AS reviewed LVN AS written statement regarding the incident with R#432 not receiving insulin. LVN AS had written that it was the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure that medication carts were checked, and expired medications pulled out. LVN AS said she used to work the 11:00 p.m. to 7:00 a.m. shift and she provided a copy of instructions that she said she used when she worked the 11:00 p.m. to 7:00 a.m. shift. The instructions were dated 12/27/16 and said the nurse on that shift would replace insulin bottles on the med cart with new insulin bottles, and on the 24th of every month, insulins would be reordered by the 11:00 p.m. to 7:00 a.m. nurse and placed on the cart with the date on the 28th of every month. This will eliminate expired insulins to be on the med cart. On 07/16/18, the DON and administrative nurses re-assessed all residents who had [DIAGNOSES REDACTED]. Inservices were completed with all staff regarding admission protocols and reviews, and clinical protocols for assessment and recognition of diabetes, and insulin administration. On 07/19/18 at 3:00 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The facility's final Plan of Removal documented: A 100% audit of all residents with a [DIAGNOSES REDACTED]. Physician or physician extender to be notified for residents who are discovered to be missing interventions such as FSBS or Lab. To be completed by LVN/ADON AN; LVN AB; LVN/MDS W and SDC/LVN BC/Education Nurse by 7/18/18. All residents with a [DIAGNOSES REDACTED]. By: LVN/ADON AN; LVN AB; LVN/MDS W; LVN DE by 7/19/19. This assessment to include: o Level of consciousness, change of orientation o Dose and time of most recent anti-hyperglycemic given; o Any signs or symptoms of infection (urine, skin/wound, upper respiratory for example) o Any recent changes in intake/thirst o Vital signs o Resident's FSBS history over the last 48 hours (if physician recommends and has ordered finger sticks) RN ADON who failed to ensure that order transcription was correct and transcribed on to Diabetic Nursing Flow Sheet has been suspended pending further assessment of her knowledge and skill base for administrative nurse position. Suspended on 7/18/18. Training on new admission process for order transcription will be completed by DON or new ADON / Quality Assurance Nurse by 7/19/18. New admission and Re-admit process for order transcription to include: o All admission orders [REDACTED] o The DON or Designee will check behind to ensure that orders are correct and have been transcribed to the correct MAR or Flow Sheet. If after hours this will occur the next morning (on weekends the Nursing Supervisor will serve as the DON Designee). o On the 2nd day (the day after admission) the DON or designee will check all MARS, TARS, and Nursing Flow Sheets to ensure that Nurses are following orders, i.e. nurses are documenting that they are administering meds as ordered. Training with all nurses on what to do when you see a [DIAGNOSES REDACTED]. When there is a [DIAGNOSES REDACTED]. Oral or subcutaneous injection, finger sticks unless physician specifies otherwise, lab testing ie, bmp, cmp, or Hgb A1c, either initial or routine ie. Quarterly. Physician should always be notified if anything is missing from orders and obtain orders immediately for prevention of adverse effects related to diabetes and to ensure residents are safe and free from harm. Training with each nurse on Physician Notification for Change of Conditions, to include: Changes in level of consciousness or orientation. Any signs or symptoms of infection Blood pressures: a. Systolic > 160; <90; b. Diastolic > 90; <50; c. Any reading out of the normal range for the resident. Any recent changes in intake / thirst; Blood Sugars (Glucose levels) a. > 300 b. < 60 c. Or, any blood sugar out of the norm for the resident or outside of any physician specified parameter. Training to be completed by DON/ADON or new ADON/Quality Assurance Nurse by 7/19/18. Training on Nurse Responsibility to Review Each [DIAGNOSES REDACTED]. This review of [DIAGNOSES REDACTED]. To be completed by DON/ADON or new ADON/Quality Asssurance Nurse by 7/19/18. Training to be completed on policy and procedure on MD Notification of Change of Condition to be completed by new ADON/NEW ADON/Education Nurse by 7/19/18. Training to be completed on importance of providing meds as prescribed to be performed by DON or new ADON / Quality Assurance Nurse by 7/19/18. Post Test to be completed by DON or Designee by end of day 7/19/18 to include items from all of the training listed above. Chart to Cart to MAR/TAR/Diabetic Flowsheet audit of all Diabetic Residents to be completed by end of day 7/19/18 to ensure that all transcription of orders for Diabetic Orders are correct. To be completed by LVN/ADON AN; DON and new ADON / Quality Assurance Nurse. Process for new admissions/re-admissions will be performed in the next morning clinical meeting by administrative nurses as follows: Charts will be taken to the morning clinical meeting, all orders will be reviewed for completion and checked for accuracy, all medications will be verified received and are in the cart, residents are receiving medications as prescribed by reviewing MARS/TARS/flow sheets. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -Interviews with 15 licensed nurses who worked all shifts and were assigned to all wings of the building revealed they had knowledge and understanding of procedures to follow for new admissions and readmissions regarding medications; understood requirements of medication administration, monitoring and documentation for diabetics; understood to notify the physician if the resident had a change of condition; understood when to review the [DIAGNOSES REDACTED]. -Surveyors reviewed 15 post-tests that were administered by the facility following inservice training on Nurse Proficiency. The post-tests were administered to nurses and covered order transcription on new admits and re-admits; procedures for residents with DM and procedures for residents with medications in the cart that were not ordered; physician notification of changes of condition; nurse responsibility for patient diagnoses; and importance of providing medications as prescribed. All nurses complete the post-test with passing scores. -Surveyors reviewed two new admissions who had entered the facility on o

Based on observation, interview and record review, the facility failed to ensure that one Resident (R#432) of seven residents reviewed for significant medication errors, was administered his medication as per his physician's orders [REDACTED].>The facility did not carry out physician's orders [REDACTED]. The facility did not follow their procedures for insulin administration by transcribing the physician's orders [REDACTED]. R#432 was transported to the emergency room at a local hospital shortly after being discharged from the facility, and he was admitted to the hospital in the Intensive Care Unit with a blood sugar of 952 and severe dehydration. This failure could affect 44 residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the affects of lack of diabetic monitoring and medication administration. The findings were: Review of the Face Sheet dated 07/10/18 revealed R#432 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R#432 was [AGE] years old and entered the facility under a Veteran's Administration respite care stay. The face sheet said he would discharge on 07/13/18. A Minimum Data Set (MDS) for R#432's respite care stay beginning 07/09/18 was not found in the chart or on the facility computerized documentation system. Review of the Start Up Orders for R#432 revealed DM (Diabetes Mellitus) as the first [DIAGNOSES REDACTED].@ (at) HS (night). A Multi-vitamin with minerals was also listed to be taken daily due to a [DIAGNOSES REDACTED]. In addition to the insulin and multivitamin with minerals, medications listed were Asa 81 mg daily; [MEDICATION NAME] 5 mg BID (twice daily); Vitamin D3 BID; Donepezil Hcl 5 mg @ HS; Magnesium [MEDICATION NAME] liquid, take one-half of a bottle as needed; [MEDICATION NAME] 20 mg HS; [MEDICATION NAME] Hcl 150 mg BID; Tamsulosin Hcl (unable to read the strength) HS; [MEDICATION NAME] Hcl (unable to read the strength); Atorvastatin Calcium 10 mg give ½ tab QHS; and [MEDICATION NAME] one capful in eight ounces of juice daily. The orders were signed by Licensed Vocational Nurse (LVN) A on 07/09/18. Review of Start Up Orders Medication Administration Record revealed no insulin had been given from 07/09/18 through 07/16/18. No multivitamin with minerals had been given. All other medications were given as ordered by the physician. Review of Admission Data Summary dated 07/09/18 revealed R#432 was admitted for a respite stay. His ADL (Activities of Daily Living) function prior to admission was that he required the assistance of one for mobility and transfer; required some assistance/cueing with eating; was incontinent of bowel and bladder and had some communication difficulty with finding words or finishing thoughts. Medications were not listed, and see attached was written in their place. R#432 had an unstable gait, weakness, was confused, disoriented or hallucinating. He had short-term and long-term memory problems, could usually understand others and make himself understood. R#432 was not in pain. R#432 was not at risk for wandering. He was at risk for weight loss due to chewing/swallowing problems. R#432 had moderately to severely impaired cognition and weakness in his upper extremities. R#432 had a Stage III pressure ulcer on his left heel, .5 X .5 X .2; and on his right heel he had a red area, Stage II pressure ulcer, 1.8 X 1.5. The Admission Data Summary dated 07/09/18 indicated R#432 was Diabetic and had [MEDICAL CONDITIONS]. He had some foot problems, open [MEDICAL CONDITION] on his foot and required application of dressings. Review of R#432's Baseline Care Plan dated 07/09/18, completed by LVN A, revealed he had some current pressure injury, and should be turned every two hours and prn, and to follow facility skin care guidelines. R#432 was also diabetic and the care plan indicated Medications as ordered; diet as ordered; observe for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The Physician order [REDACTED]. Review of closed records revealed R#432 had been at the facility for previous respite care stays, from 03/16/18 to 03/18/18, and again from 05/11/18 to 05/13/18. R#432 had physician orders [REDACTED]. On initial tour of the facility on 07/16/18 at 10:23 a.m., R#432 was not in his room. At 4:15 p.m. on 07/16/18, the ADON said R#432 had been at the facility on a respite stay and had been picked up by a family member early in the afternoon of 07/16/18. Review of emergency room (ER) records dated 07/16/18 at 3:17 p.m. revealed R#432 was alert, disoriented times three, lethargic, and would follow commands but would not respond when asked questions. He was picked up from a nursing home and looked dehydrated. The chief complaint was altered mental status. FM came in with him and said he was not responding to her as he was complaining of pain but unable to tell her where he was hurting. FM said he would normally converse without any issue, though he did have some early dementia but had never been this altered. Associated symptoms were less active, weakness. Review of the ER Physician's Examination on 07/16/18 at 4:37 p.m. revealed R#432's vital signs were within normal limits with the exception of his heart rate which was 114. R#432 looked severely malnourished, dehydrated with dry mucous membranes, and was found to have a sugar greater than what our machine reads in triage therefore he was urgently moved back to room [ROOM NUMBER] for evaluation. History is provided mostly by family as the patient does not speak. The ER physician further commented that R#432 was found to have a sugar of 952 in triage; IV fluids and an insulin drip were started. R#432's corrected sodium was 176. He will be admitted to ICU. In an interview at 11:30 a.m. on 07/17/18, the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) DE fed R#432 lunch on 07/16/18, and R#432's Family Member (FM) picked him up around 2:00 p.m. on 07/17/18. The DON said she had spoken to R#432's FM on 07/16/18, and the FM said that she took R#432 to the hospital after picking him up at the facility. The DON said the FM told her R#432 was admitted to the hospital with [REDACTED]. The DON said she reviewed R#432's chart and found that there were no treatment records. The DON pointed at R#432's admitting physician's orders [REDACTED].#432 and no orders for doing finger sticks. The DON said she suspended the admitting nurse because she did not transcribe the insulin order to the diabetic or finger stick MARS. The DON said, What we have is a multi-system failure here. The DON said she had only been at the facility a few days, with a start date of 07/11/18, and she was just starting to look at the processes and concerns of the facility and was not aware of any concerns regarding R#432 until she received a call from his FM on 07/16/18. The DON said the processes for admissions had not been followed. The DON said charts were not reviewed in the morning meeting, and they should be reviewed. The DON said she reviewed new admissions daily. The DON said the facility began reviewing any residents who had codes for diabetes (on their MDS) and reviewed their medication cart-to MAR-to Physician order [REDACTED].#432 was a new resident. The DON said the admitting nurse should have called and gotten order from the physician for finger sticks. In the interview at 11:30 a.m. on 07/17/18, surveyor asked the DON what the complications of missing 14 insulin doses, the number of doses of insulin missed by R#432, would be; the DON responded that the resident could go into a coma, die or have a [MEDICAL CONDITION], and said It's a big danger. When asked what Policies and Procedures (P and P's) were in place regarding admissions and treatments, the DON responded that she did not know since she had been at the facility such a short time and had not gotten involved with the P and P's yet. In the interview at 11:30 a.m. on 07/17/18, the DON said the nurse who discharged R#432 discharged him with an insulin vial that expired in (MONTH) (YEAR). The LVN who discharged him, the DON said, did not seem to think anything of that In an interview at 2:03 p.m. on 07/17/18, R#432's FM said she was R#432's caregiver and he lived with her. FM said R#432 had two [MEDICAL CONDITION] and a [MEDICAL CONDITION] in (YEAR). FM said R#432 was able to talk to her a little bit but had dementia and could not talk very much. R#432 was paralyzed on his left side and used a wheelchair; FM said R#432 needed help to eat, his food was a chopped texture and his drinks were nectar thick. FM said R#432's blood sugars ran 180 or 190. FM said she gave R#432 his morning insulin injection on 07/09/18 before she took him to the facility and thought his blood sugar was 160 at that time. FM said she checked R#432's blood sugar three times a day; before breakfast, before lunch and before dinner. R#432 said the Veterans Administration allowed respite care for R#432 for up to 30 days a year. FM said she and her family went out of town while R#432 was at the facility. FM said R#432 had been to the facility for respite three or four times and this stay from 07/09/18 to 07/16/18 completed his 30 days of respite that he was allowed for the year. FM said R#432 was a very good eater. In the interview at 2:03 p.m. on 07/17/18, FM said she gave R#432's medication to the facility when he was admitted . FM said R#432 had a mood disorder medication, Tamsulosin for his prostate; two vitamins in the morning; a heart pill twice daily; and insulin. FM said she took a brand-new bottle of insulin to the facility and it was not touched during his stayed there that she could tell. FM said the VA sent R#432 a new bottle of insulin about a month and a half ago. FM said she had removed the cap from the bottle of insulin. FM said the facility called her on Friday, 7/13/18, to come pick up R#432, but she said that the respite care was supposed to last until 07/16/18, and the facility agreed to keep him there until 07/16/18. In the interview at 2:03 p.m. on 07/17/18, FM said she called and spoke to LVN AS on 07/16/18 to see how R#432 was doing. LVN AS said R#432 was doing good, sitting at the nurse's station. FM said she told LVN AS that she would be at the facility shortly to pick R#432 up. FM said that when she went to pick up R#432 about 2:00 p.m. on 07/16/18, she found R#432 in his room. FM said R#432's eyes were sunken in and he looked ten pounds lighter. FM said she went to the nurse's station and asked how R#432 had been eating, and said that R#432 looked sick, eyes sunken in and he looked skinny. LVN AS was not there as she was getting his medication. The people at the nurse's station said R#432 was eating 75% of his food and was on nectar liquids. FM said she signed R#432's discharge papers and after taking him out of the facility, she decided to take R#432 to the emergency room . FM said R#432's tongue was sticking out and he was not able to respond. R#432's arms were shaking and when she asked if he was ok, he gave no response. FM said after waiting one and one-half hours at the emergency room (ER), R#432 was taken back to a room and blood work was initiated. FM said about 5:30 p.m. on 07/16/18, she was told R#432 had high blood sugar that was so high their monitor could not read it. The ER later determined R#432's blood sugar was 952 and his sodium level was 169. FM said she called the facility and spoke to the DON on 07/16/18 to find out what was going on with R#432 and about 6:00 p.m. or 6:30 p.m., she was told the facility never gave R#432 his insulin. FM said in the morning of 07/17/18, she received a call from an ICU nurse that R#432 was severely dehydrated and had three open sores on his bottom. FM said she told the Administrator that R#432 went in with a pressure ulcer on his left heel that was in the process of healing and he did not have pressure ulcers on his bottom. FM said when she picked up R#432 from the facility, the pressure ulcer on his left heel was open and draining. FM said R#432's blood sugar had been responding to his care at the hospital and was 191 about an hour ago. FM said R#432 was still hallucinating and very confused. FM said she was angry because the facility never notified her of any problems with R#432's insulin, and he was also crying because the ulcers on his bottom were hurting him. FM said, I left him there so that they could take care of him and I came home, and he was dying. FM said R#432 raised her and she has been taking care of him since (YEAR). In an interview at 3:06 p.m. on 07/17/18, LVN P said she did not remember anything regarding medication administration for R#432. LVN P said R#432 was alert, up in a wheelchair with assistance, and needed total care. LVN P said she did not remember whether R#432 required finger sticks or insulin and said it would help if she could look at the finger stick book. LVN P said if R#432 was no longer at the facility, insulin that was given would only be documented in the finger stick book. LVN P said the handwritten MAR-finger stick book was in the medication cart. LVN P reviewed R#432's startup orders, which had medications listed and initials for medications that were administered. LVN P said she recognized her signature on the start up orders and said she did not recall seeing an order for [REDACTED]. LVN P said if she had seen the order for insulin, she would have written it to put in the finger stick book and would have put it in the finger stick book. When asked what a nurse should do if there were no orders for checking blood sugars for an insulin dependent diabetic, LVN P answered that they were supposed to have finger sticks so that blood sugars could be tracked. LVN P said she did not see orders for finger sticks on R#432's start up orders. LVN P said it was everyone who took care of R#432's responsibility to follow up on insulin/finger stick orders. In the interview at 3:06 p.m. on 07/17/18, LVN P said the admitting nurse would write all medications down on the start up orders and then complete the Diabetic Flow Sheet and put it in the diabetic book. LVN P said the insulin column on the start up orders was blank; she said she would wonder if it was ever given and would call the doctor. LVN P said finger sticks and insulin were never documented on the startup MAR and were always documented on the diabetic book. LVN P said insulin was stored in the medication cart and unopened insulin was stored in the refrigerator. In an interview at 3:41 p.m. on 07/17/18, the DON said she looked through the finger stick/diabetic book twice after she was called by R#432's FM, and she did not find anything regarding R#432's finger sticks/insulin. In an interview at 4:47 p.m. on 07/17/18, LVN A said she admitted R#432 on 07/09/18. LVN A said she had three days of orientation and the orientation did not include the admission process. LVN A said it was only the second admission she had done, and she asked LVN AS and RN/ADON AK to review the admission for R#432 because she wanted to be sure it was done correctly. LVN A said the next day she asked RN/ADON AK if she had completed R#432's admission correctly, and RN/ADON AK responded that she had not reviewed it but from what she knew it was done okay and she would look at it. LVN A said she did a head to toe assessment of R#432, looked at his medications from home and compared them to what the physician ordered. LVN A said the medications brought in by R#432's FM were in a little box; she said insulin was in the little box and was written on the startup orders. LVN A said the medications were already written out by LVN AS on R#432's start up orders when she proceeded with his admission, and R#432 had already arrived at the facility. LVN A said she reviewed the medications with the Nurse Practitioner who oversaw R#432's care at the facility, and she crossed out four medications and wrote error because they were no longer being ordered. In the interview on 07/17/18 at 4:47 p.m., LVN A said she was a relief worker and did not know the facility procedure of transcribing insulin and finger stick orders to the Diabetic MAR and putting it in the diabetic book. LVN A said she did not notice that there was no order for finger sticks for R#432 but she knew as a nurse that they should have been done. In an interview at 5:08 p.m. on 07/17/18, LVN R said she worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she remembered R#432 and said, He's diabetic. I checked his sugar when he was here before. He was here for respite. I saw insulin in the med cart. There was no paper for him in the diabetic book, so I thought, Okay, I guess we don't check his sugar. Why did they bring his insulin? LVN R said there were things marked out on the MAR and she did not see any time on the startup orders for insulin to be given. LVN R said, A lot of us missed it. Where's the sheet? All diabetic stuff goes on one sheet. LVN R said she told LVN AS, who worked 7:00 a.m. to 3:00 p.m., that she was wondering why they were not checking his sugar. LVN R said LVN AS said she wondered the same thing. Surveyor asked LVN R if she called R#432's physician to clarify whether insulin should be given to him, and she replied she did not call the physician because he could not practice any longer. Surveyor asked if she notified her supervisor that there were concerns regarding R#432's insulin administration, and she replied that she answered to RN/ADON AK and she did not inform RN/ADON AK. LVN R said she overlooked doing that. LVN R said she should have notified someone. LVN R said they also missed administering R#432's Vitamins with minerals. When asked what the possible consequences were of not giving insulin to a diabetic when it was ordered, LVN R responded that the resident could go into a coma, go to the hospital or die from it. In an interview at 5:22 p.m. on 07/17/18, LVN CB said he worked at the facility since the end of (MONTH) (YEAR). LVN CB said R#432's orders were never transcribed to his MAR. LVN CB said R#432's startup orders were confusing to pass medications, with marks through some of the medications and other things changed. LVN CB said the insulin and minerals were at the bottom of the start up orders. He said they should have put the hours for the insulin to be given in the column next to the medication. LVN CB said insulin should have been given at 7:00 in the morning and the minerals should have been given daily. LVN CB said no doses of insulin were given and normally there should be an insulin flow sheet, but R#432 did not have anything in the diabetic flow book. LVN CB said R#432 did not have insulin in the med cart. The insulin was expired, he said, and was usually in the top middle drawer in the cart, but instead it was put in the refrigerator. LVN CB said the third shift stocked the med carts. LVN CB said RN/ADON AK said R#42's insulin was in the refrigerator. LVN CB said the insulin was not in the cart as he would have noticed it. LVN CB said he did not know R#432 was diabetic. LVN CB said the diabetic book was part of his orientation and all halls had them. In an interview at 5:45 p.m. on 07/17/18, LVN CR said she worked at the facility since (MONTH) 5, (YEAR). LVN CR said she was oriented on the use of the diabetic book. LVN CR said she assisted R#432 with eating lunch on 07/16/18, just before his FM picked him up from the facility. LVN CR said R#432 tolerated the meal well; when she moved him back in his wheelchair because he was sitting forward, LVN CR made a sighing sound when she moved him back. LVN CR said R#432 ate his food, drank juice, water and milk, and tried to grab liquids. LVN CR said liquids fell out of R#432's mouth as he drank. LVN CR said R#432 drank thickened liquids but she did not remember the texture of his food; he ate more than 80% of his meal, she said. LVN CR said she had no awareness R#432 was on insulin and she never administered medications to him. In an interview at 7:15 p.m. on 07/17/18, LVN A said she kept notes of everything she did during the day at work. She said she remembered that she did not find any insulin in R#432's box of medications that his FM brought from home. LVN A said she remembered that insulin as written on the MAR and she verified these orders with R#432's physician. LVN A said other shifts would have written on the MAR and would have seen it. In an interview at 7:23 p.m. on 07/17/18, RN/ADON AK said she remembered R#432 from previous admission. RN/ADON AK said after she found out R#432 never received insulin, she noted that the insulin was written near the bottom of the start up orders and was supposed to be transcribed to the diabetic MAR, but it never made it on there. RN/ADON AK said LVN A checked in R#432's medications and she was the admitting nurse. RN/ADON AK said she was notified by LVN AS after she discharged R#432 that she found a vial of insulin and it was expired and it was from (MONTH) (YEAR); that was when everything came to light at the end of the day on 07/16/18. Upon discharge on 07/16/18, RN/ADON AK said she stumbled upon an expired insulin vial in the refrigerator of the med room and she gave it back to FM. RN/ADON AK said she did not know how the insulin ended up in the refrigerator. RN/ADON AK said when a new resident was admitted , she checked the MARS for discrepancies. When asked if she reviewed R#432's MARS for discrepancies, RN/ADON AK said she skimmed over it but did not check the MAR and see that it was transcribed to the diabetic MAR. RN/ADON AK said it looked like a standard admission. RN/ADON AK said she saw that R#432 had insulin listed at the bottom of the start up orders. RN/ADON AK said LVN A had over three days of orientation on the floor, including shadowing another nurse. RN/ADON AK said LVN A had knowledge of the diabetic book, but she got overwhelmed and she forgot a step. RN/ADON AK said no one said they knew who put the insulin in the refrigerator. RN/ADON AK said it was not that unusual that orders were received for giving insulin without doing finger sticks as some physicians did not order accuchecks of blood sugar. RN/ADON AK said she would have expected her 7:00 a.m. to 3:00 p.m. nurses or her night shift to catch that the insulin was not transcribed to the diabetic MAR, and she said she expected more from herself. In an interview at 7:48 p.m. on 07/17/18, LVN A said she verified R#432's orders with a Nurse Practitioner (NP). Regarding the insulin, R#432 was supposed to be given 15 units in the morning and seven units in the evening. LVN A said she would have written in the nurse's notes if she had verified whether the NP wanted finger sticks to be done. LVN A said there was no Policies and Procedures book to look through to see if she did the admission correctly. LVN A said she could not remember if she administered any insulin to R#432. LVN A said she worked for the corporation that owned the facility ten to [AGE] years ago, and did not remember a procedure for a diabetic book. In an interview at 8:11 p.m. on 07/17/18, FM said R#432's blood sugar was at 150 but he was still dehydrated and in ICU at the hospital. FM said she was sure she gave the facility a whole new bottle of insulin when she took R#432 to the facility on [DATE], but she did remember removing the cap. FM said she would check the expiration date of the insulin. In an interview at 9:00 p.m. on 07/17/18, FM said the insulin she took to the facility on [DATE] was filled on 02/14/18 and had an expiration date of 01/2020. The insulin also said to discard the bottle after 02/13/19. FM said she gave the medications to LVN AS (calling her by her first name and describing her) when she took R#432 to the facility on [DATE]. FM said when she picked up R#432 on 07/16/18, she noticed that the outside of the box of insulin was written in black marker, 03-17-18. FM said R#432's blood sugar was down to 115 and his labs were looking good, and the hospital was going to see if he would eat a little bit. In an interview at 9:58 a.m. on 07/18/18, LVN AS said she worked the 7:00 a.m. to 3:00 p.m. shift. LVN AS said she received R#432 alert on the day he came into the facility. LVN AS said she wrote the headers and footers of the admission packets and wrote down his medications but did not write down the times he took them. LVN AS said R#432 got to the facility at 2:45 p.m., and because she got off work at 3:00 p.m., she did not do the admission. LVN AS said she gave the incoming nurse, LVN A, report, and R#432 and FM went straight into the Social Worker's office. LVN AS said on the morning that R#432 was discharged , 07/16/18, LVN R gave her report and told her R#432's insulin was expired and did not need to be on the cart. The date that it was expired was written in black on the side of the insulin box; she looked at the box and it was opened in (MONTH) and did not have an expiration date. LVN AS said she knew it was only good for 28 days. She put it in the refrigerator around 7:00 a.m. When R#432 left, she put all of R#432's medications in a bag and gave them to his FM. In the interview at 9:58 a.m. on 07/18/18, LVN AS said she passed medications to R#432 on 07/09/18, 07/10/18, 07/11/18, 07/15/18 and 07/16/18. She said she passed medications to R#432 when he was at the facility before this respite stay, and she now remembered he took insulin before. LVN AS said she probably did see that R#432 had insulin written on the start up orders, and the list of medications came from a fax the facility received from the Veterans Administration with R#432's [DIAGNOSES REDACTED]. LVN AS said she remembered R#432 was supposed to be given insulin around 9:00 p.m. LVN AS said LVN A was new at the facility. LVN AS said if it was her admission, she would have rewritten the start up orders and put an asterisk on them and would have put the insulin on the insulin sheet. The start up orders would have been faxed to the pharmacy. LVN AS said she did not tell LVN A to transcribe to the insulin record. It was automatic, LVN AS said, for RN/ADON AK to review and tell her what need to be corrected on admissions. LVN AS said a resident could die if he missed his insulin for a week. In an interview at 10:30 a.m. on 07/18/18, the DON said she was in the process of ensuring everyone who handled admissions knew the policies and procedures for them. The DON said she did not understand who put the black marker with the date 03-17-18 on R#432's insulin. In an interview on 07/20/18 at 11:00 a.m., LVN R said she got report on 07/09/18 from LVN A. LVN R worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she said she knew she needed to check R#432's blood sugar and said there should have been orders for accuchecks, saying, Yes, absolutely, no doubt about it. In an interview on 07/20/18 at 5:26 p.m., LVN A said that she looked at some notes that she kept at home regarding medications that she gave during her shifts, and she found that she had given seven units of insulin to R#432 once or twice when he was at the facility. She said she also remembered checking his blood sugar once or twice before giving him his insulin. She said she found the insulin in the top drawer of the medication cart. After that, she said she was on vacation. In an interview at 10:55 a.m. on 07/21/18, the DON said each nurse was responsible for ensuring the medications were correct. The DON said it was not the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure the insulin was not expired. In an interview and record review at 12:10 p.m. on 07/21/18, surveyor and LVN AS reviewed LVN AS written statement regarding the incident with R#432 not receiving insulin. LVN AS had written that it was the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure that medication carts were checked, and expired medications pulled out. LVN AS said she used to work the 11:00 p.m. to 7:00 a.m. shift and she provided a copy of instructions that she said she used when she worked the 11:00 p.m. to 7:00 a.m. shift. The instructions were dated 12/27/16 and said the nurse on that shift would replace insulin bottles on the med cart with new insulin bottles, and on the 24th of every month, insulins would be reordered by the 11:00 p.m. to 7:00 a.m. nurse and placed on the cart with the date on the 28th of every month. This will eliminate expired insulins to be on the med cart. On 07/19/18 at 3:00 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The facility's final Plan of Removal documented: A 100% audit of all residents with a [DIAGNOSES REDACTED]. Physician or physician extender to be notified for residents who are discovered to be missing interventions such as FSBS or Lab. To be completed by LVN/ADON AN; LVN AB; LVN/MDS W and SDC/LVN BC/Education Nurse by 7/18/18. All residents with a [DIAGNOSES REDACTED]. By: LVN/ADON AN; LVN AB; LVN/MDS W; LVN DE by 7/19/19. This assessment to include: o Level of consciousness, change of orientation o Dose and time of most recent anti-hyperglycemic given; o Any signs or symptoms of infection (urine, skin/wound, upper respiratory for example) o Any recent changes in intake/thirst o Vital signs o Resident's FSBS history over the last 48 hours (if physician recommends and has ordered finger sticks) RN ADON who failed to ensure that order transcription was correct and transcribed on to Diabetic Nursing Flow Sheet has been suspended pending further assessment of her knowledge and skill base for administrative nurse position. Suspended on 7/18/18. Training on new admission process for order transcription will be completed by DON or new ADON / Quality Assurance Nurse by 7/19/18. New admission and Re-admit process for order transcription to include: o All admission orders [REDACTED] o The DON or Designee will check behind to ensure that orders are correct and have been transcribed to the correct MAR or Flow Sheet. If after hours this will occur the next morning (on weekends the Nursing Supervisor will serve as the DON Designee). o On the 2nd day (the day after admission) the DON or designee will check all MARS, TARS, and Nursing Flow Sheets to ensure that Nurses are following orders, i.e. nurses are documenting that they are administering meds as ordered. Training with all nurses on what to do when you see a [DIAGNOSES REDACTED]. When there is a [DIAGNOSES REDACTED]. Oral o

Based on observation, interview and record review, the facility failed to ensure that one Resident (R#432) of five newly admitted residents with [DIAGNOSES REDACTED]. The facility did not carry out physician's orders [REDACTED]. The facility did not follow their procedures for insulin administration by transcribing the physicians orders for insulin to the diabetic MAR (Medication Administration Record) in the diabetic book used by nurses who administered insulin. The facility did not consult with R #432's physician for orders for blood glucose monitoring since R #432 had a [DIAGNOSES REDACTED]. The facility did not follow their processes for newly admitted residents when the Assistant Director of Nurses (ADON) failed to review R#432's admission records for accuracy and for following facility admission procedures. R#432 was transported to the emergency room at a local hospital shortly after being discharged from the facility, and he was admitted to the hospital in the Intensive Care Unit with a blood sugar of 952 and severe dehydration. R#432 also had three Stage II pressure ulcers on his buttocks that were not present when he entered the facility. This failure could affect 44 residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the affects of lack of diabetic monitoring and medication administration. The above failures resulted in an IJ situation on 07/18/18. While the IJ was removed on 07/21/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. The findings included: Review of the Face Sheet dated 07/10/18 revealed R#432 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R#432 was [AGE] years old and entered the facility under a Veteran's Administration respite care stay. The face sheet said he would discharge on 07/13/18. A Minimum Data Set (MDS) for the respite care stay beginning 07/09/18 was not found in the chart or on the facility computerized documentation system. Review of the Start Up Orders for R#432 revealed DM (Diabetes Mellitus) as the first [DIAGNOSES REDACTED].@ (at) HS (night). A Multi-vitamin with minerals was also listed to be taken daily due to a [DIAGNOSES REDACTED]. In addition to the insulin and multivitamin with minerals, medications listed were Asa 81 mg daily; [MEDICATION NAME] 5 mg BID (twice daily); Vitamin D3 BID; Donepezil Hcl 5 mg @ HS; Magnesium [MEDICATION NAME] liquid, take one-half of a bottle as needed; [MEDICATION NAME] 20 mg HS; [MEDICATION NAME] Hcl 150 mg BID; Tamsulosin Hcl (unable to read the strength) HS; [MEDICATION NAME] Hcl (unable to read the strength); Atorvastatin Calcium 10 mg give ½ tab QHS; and [MEDICATION NAME] one capful in eight ounces of juice daily. The orders were signed by Licensed Vocational Nurse (LVN) A on 07/09/18. Review of Start Up Orders Medication Administration Record revealed no insulin had been given from 07/09/18 through 07/16/18. No multivitamin with minerals had been given. All other medications were given as ordered by the physician. Review of Admission Data Summary dated 07/09/18 revealed R#432 was admitted to the facility for a respite stay. His ADL (Activities of Daily Living) function prior to admission was that he required the assistance of one for mobility and transfer; required some assistance/cueing with eating; was incontinent of bowel and bladder and had some communication difficulty with finding words or finishing thoughts. Medications were not listed, and see attached was written in their place. R#432 had an unstable gait, weakness, was confused, disoriented or hallucinating. He had short-term and long-term memory problems but could usually understand others and make himself understood. R#432 was not in pain. R#432 was not at risk for wandering. He was at risk for weight loss due to chewing/swallowing problems. R#432 had moderately to severely impaired cognition and weakness in his upper extremities. R#432 had a Stage III pressure ulcer on his left heel, .5 X .5 X .2; and on his right heel he had a red area, Stage II pressure ulcer, 1.8 X 1.5. The Admission Data Summary dated 07/09/18 indicated R#432 was Diabetic and had [MEDICAL CONDITIONS]. He had some foot problems, open [MEDICAL CONDITION] on his foot and required application of dressings. Review of R#432's Baseline Care Plan dated 07/09/18, completed by LVN A, revealed he had some current pressure injury, and should be turned every two hours and prn, and to follow facility skin care guidelines. R#432 was also diabetic and the care plan indicated Medications as ordered; diet as ordered; observe for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The Physician order [REDACTED]. Review of closed records revealed R#432 had been at the facility for previous respite care stays, from 03/16/18 to 03/18/18, and again from 05/11/18 to 05/13/18. R#432 had physician orders [REDACTED]. On initial tour of the facility on 07/16/18 at 10:23 a.m., R#432 was not in his room. At 4:15 p.m. on 07/16/18, the ADON said R#432 had been at the facility on a respite stay and had been picked up by a family member early in the afternoon of 07/16/18. Review of emergency room (ER) records dated 07/16/18 at 3:17 p.m. revealed R#432 was alert, disoriented times three, lethargic, and would follow commands but would not respond when asked questions. He was picked up from a nursing home and looked dehydrated. The chief complaint was altered mental status. FM came in with him and said he was not responding to her as he was complaining of pain but unable to tell her where he was hurting. FM said he would normally converse without any issue, though he did have some early dementia, but he had never been this altered. Associated symptoms were less active, weakness. Review of the ER Physician's Examination on 07/16/18 at 4:37 p.m. revealed R#432's vital signs were within normal limits with the exception of his heart rate which was 114. R#432 looked severely malnourished, dehydrated with dry mucous membranes, and was found to have a sugar greater than what our machine reads in triage therefore he was urgently moved back to room [ROOM NUMBER] for evaluation. History is provided mostly by family as the patient does not speak. The ER physician further commented that R#432 was found to have a sugar of 952 in triage; IV fluids and an insulin drip were started. R#432's corrected sodium was 176. He will be admitted to ICU. In an interview at 11:30 a.m. on 07/17/18, the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) DE fed R#432 lunch on 07/16/18, and R#432's Family Member (FM) picked him up around 2:00 p.m. on 07/17/18. The DON said R#432's FM called her on 07/16/18, and said that she took R#432 to the hospital after picking him up at the facility and he was admitted to ICU with a blood sugar of 952. The DON said she reviewed R#432's chart and found that there were no treatment records. The DON pointed at R#432's admitting physician's orders [REDACTED].#432 and no orders for doing finger sticks. The DON said she suspended the admitting nurse because the admitting nurse did not transcribe the insulin order to the diabetic or finger stick MARS. The DON said, What we have is a multi-system failure here. The DON said she had only been at the facility a few days, with a start date of 07/11/18, and she was just starting to look at the processes and concerns of the facility and was not aware of any concerns regarding R#432 until she received a call from his FM on 07/16/18. The DON said the processes for admissions had not been followed. The DON said charts were not reviewed in the morning meeting, and they should have been reviewed. The DON said she reviewed new admissions daily. The DON said the facility began reviewing any residents who had codes for diabetes (on their MDS) and reviewed their medication cart-to-MAR-to-Physician order [REDACTED].#432 was a new resident. The DON said the admitting nurse should have called and gotten orders from the physician for finger sticks. In the interview at 11:30 a.m. on 07/17/18, surveyor asked the DON what the complications of missing 14 insulin doses, the number of doses of insulin missed by R#432, would be; the DON responded that the resident could go into a coma, die or have a [MEDICAL CONDITION], and said It's a big danger. When asked what Policies and Procedures (P and P's) were in place regarding admissions and treatments, the DON responded that she did not know since she had been at the facility such a short time and had not gotten involved with the P and P's yet. In the interview at 11:30 a.m. on 07/17/18, the DON said the nurse who discharged R#432 discharged him with an insulin vial that expired in (MONTH) (YEAR). The LVN who discharged him, the DON said, did not seem to think anything of that. In an interview at 2:03 p.m. on 07/17/18, R#432's FM said she was R#432's caregiver and he lived with her. FM said R#432 had two [MEDICAL CONDITION] and a [MEDICAL CONDITION] in (YEAR). FM said R#432 was able to talk to her a little bit but had dementia and could not talk very much. R#432 was paralyzed on his left side and used a wheelchair; FM said R#432 needed help to eat, his food was a chopped texture and his drinks were nectar thick. FM said R#432's blood sugars ran 180 or 190. FM said she gave R#432 his morning insulin injection on 07/09/18 before she took him to the facility and thought his blood sugar was 160 at that time. FM said she checked R#432's blood sugar three times a day; before breakfast, before lunch and before dinner. R#432 said the Veterans Administration allowed respite care for R#432 for up to 30 days a year. FM said she and her family went out of town while R#432 was at the facility. FM said R#432 had been to the facility for respite three or four times and this stay from 07/09/18 to 07/16/18 completed his 30 days of respite that he was allowed for the year. FM said R#432 was a very good eater. In the interview at 2:03 p.m. on 07/17/18, FM said she gave R#432's medication to the facility when he was admitted . FM said R#432 had a mood disorder medication, Tamsulosin for his prostate; two vitamins in the morning; a heart pill twice daily; and insulin. FM said she took a brand-new bottle of insulin to the facility and it was not given during his stay there that she could tell. FM said the VA sent R#432 a new bottle of insulin about a month and a half ago. FM said she had removed the cap from the bottle of insulin. FM said the facility called her on Friday, 7/13/18, to come pick up R#432, but she said that the respite care was supposed to last until 07/16/18, and the facility agreed to keep him there until 07/16/18. In the interview at 2:03 p.m. on 07/17/18, FM said she called and spoke to LVN AS on 07/16/18 to see how R#432 was doing. LVN AS said R#432 was doing good, sitting at the nurse's station. FM said she told LVN AS that she would be at the facility shortly to pick R#432 up. FM said that when she went to pick up R#432 about 2:00 p.m. on 07/16/18, she found R#432 in his room. FM said R#432's eyes were sunken in and he looked ten pounds lighter. FM said she went to the nurse's station and asked how R#432 had been eating, and said that R#432 looked sick, eyes sunken in and he looked skinny. LVN AS was not there as she was getting his medication. The people at the nurse's station said R#432 was eating 75% of his food and was on nectar liquids. FM said she signed R#432's discharge papers and after taking him out of the facility, she decided to take R#432 to the emergency room . FM said R#432's tongue was sticking out and he was not able to respond. R#432's arms were shaking and when she asked if he was ok, he gave no response. FM said after waiting one and one-half hours at the emergency room (ER), R#432 was taken back to a room and blood work was initiated. FM said about 5:30 p.m. on 07/16/18, she was told R#432 had high blood sugar that was so high their monitor could not read it. The ER later determined R#432's blood sugar was 952 and his sodium level was 169. FM said she called the facility and spoke to the DON on 07/16/18 to find out what was going on with R#432, and at about 6:00 p.m. or 6:30 p.m., she was told the facility never gave R#432 his insulin. FM said in the morning of 07/17/18, she received a call from an ICU nurse that R#432 was severely dehydrated and had three open sores on his bottom. FM said she told the Administrator that R#432 went in with a pressure ulcer on his left heel that was in the process of healing and he did not have pressure ulcers on his bottom. FM said when she picked up R#432 from the facility, the pressure ulcer on his left heel was open and draining. FM said R#432's blood sugar had been responding to his care at the hospital and was 191 about an hour ago. FM said R#432 was still hallucinating and very confused. FM said she was angry because the facility never notified her of any problems with R#432's insulin, and he was also crying because the ulcers on his bottom were hurting him. FM said, I left him there so that they could take care of him and I came home, and he was dying. FM said R#432 raised her and she has been taking care of him since (YEAR). In an interview at 3:06 p.m. on 07/17/18, LVN P said she did not remember anything regarding medication administration for R#432. LVN P said R#432 was alert, up in a wheelchair with assistance, and needed total care. LVN P said she did not remember whether R#432 required finger sticks or insulin and said it would help if she could look at the finger stick book. LVN P said if R#432 was no longer at the facility, insulin that was given would only be documented in the finger stick book. LVN P said the handwritten MAR-finger stick book was on the medication cart. LVN P reviewed R#432's startup orders, which had medications listed and initials for medications that were administered. LVN P said she recognized her signature on the start up orders and said she did not recall seeing an order for [REDACTED]. LVN P said if she had seen the order for insulin, she would have written out a page for his diabetes and would have put it in the finger stick book. When asked what a nurse should do if there were no orders for checking blood sugars for an insulin dependent diabetic, LVN P answered that they were supposed to have finger sticks so that blood sugars could be tracked. LVN P said she did not see orders for finger sticks on R#432's start up orders. LVN P said it was everyone's responsibility if they took care of R#432 to follow up on insulin/finger stick orders. In the interview at 3:06 p.m. on 07/17/18, LVN P said the admitting nurse would write all medications down on the start up orders and then complete the Diabetic Flow Sheet and put it in the diabetic book. LVN P said the insulin column on the start up orders was blank; she said she would wonder if it was ever given and would call the doctor. LVN P said finger sticks and insulin were never documented on the startup MAR and were always documented on the diabetic book. In an interview at 3:41 p.m. on 07/17/18, the DON said she looked through the finger stick/diabetic book twice after she was called by R#432's FM on 07/16/18, and she did not find anything regarding R#432's finger stick or insulin. The DON confirmed R #432 did not have oders for blood glucose monitoring. The DON said the nurses, any nurse involved with R #432's care, should have identified that there were no fingerstick orders and should have called the physician to get orders since R #432 was a diabetic and was prescribed daily insulin administration. The DON stated the importance of fingersticks was to monitor and track the residents blood glucose levels and evaluate whether his prescribed insulin was effective. The DON said if the blood glucose level was not known, administration of the prescribed insulin could cause [DIAGNOSES REDACTED] (low blood sugar) placing the resident at risk for coma and/or death. The DON further explained that if the blood glucose level was not known, the resident's blood sugar to be too high and potentially cause coma or death. In an interview at 4:47 p.m. on 07/17/18, LVN A said she admitted R#432 on 07/09/18. LVN A said she had three days of orientation and the orientation did not include the admission process. LVN A said it was only the second admission she had done, and she asked LVN AS and RN/ADON AK to review the admission for R#432 because she wanted to be sure it was done correctly. LVN A said the next day she asked RN/ADON AK if she had completed R#432's admission correctly, and RN/ADON AK responded that she had not reviewed it but from what she knew it was done okay and she would look at it. LVN A said she did a head to toe assessment of R#432, looked at his medications from home and compared them to what the physician ordered. LVN A said the medications brought in by R#432's FM were in a little box; she said insulin was in the little box and was written on the startup orders. LVN A said the medications were already written out by LVN AS on R#432's start up orders when she proceeded with his admission, and R#432 had already arrived at the facility. LVN A said she reviewed the medications with the Nurse Practitioner who oversaw R#432's care at the facility, and she crossed out four medications and wrote error because they were no longer being ordered. In the interview on 07/17/18 at 4:47 p.m., LVN A said she was a relief worker and did not know the facility procedure of transcribing insulin and finger stick orders to the Diabetic MAR and putting it in the diabetic book. LVN A said she did not notice that there was no order for finger sticks for R#432 but she knew as a nurse that they should have been done. In an interview at 5:08 p.m. on 07/17/18, LVN R said she worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she remembered R#432 and said, He's diabetic. I checked his sugar when he was here before. He was here for respite. I saw insulin in the med cart. There was no paper for him in the diabetic book, so I thought, Okay, I guess we don't check his sugar. Why did they bring his insulin? LVN R said there were things marked out on the MAR and she did not see any time on the startup orders for insulin to be given. LVN R said, A lot of us missed it. Where's the sheet? All diabetic stuff goes on one sheet. LVN R said she told LVN AS, who worked 7:00 a.m. to 3:00 p.m., that she (LVN R) was wondering why they were not checking his sugar. LVN R said LVN AS said she wondered the same thing. Surveyor asked LVN R if she called R#432's physician to clarify whether insulin should be given to him, and she replied she did not call the physician because he could not practice any longer (surveyor was later advised that LVN R was mistaken). Surveyor asked LVN R if she notified her supervisor that there were concerns regarding R#432's insulin administration, and she replied that she answered to RN/ADON AK and she did not inform RN/ADON AK. LVN R said she overlooked doing that. LVN R said she should have notified someone. LVN R said they also missed administering R#432's Vitamins with minerals. When asked what the possible consequences were of not giving insulin to a diabetic when it was ordered, LVN R responded that the resident could go into a coma, go to the hospital or die from it. In an interview at 5:22 p.m. on 07/17/18, LVN CB said he worked at the facility since the end of (MONTH) (YEAR). LVN CB said R#432's orders were never transcribed to his MAR. LVN CB said R#432's startup orders were confusing to pass medications, with marks through some of the medications and other things changed. LVN CB said the insulin and minerals were at the bottom of the start up orders. He said they should have put the hours for the insulin to be given in the column next to the medication. LVN CB said insulin should have been given at 7:00 in the morning and the minerals should have been given daily. LVN CB said no doses of insulin were given and normally there should be an insulin flow sheet, but R#432 did not have anything in the diabetic flow book. LVN CB said R#432 did not have insulin in the med cart. The insulin was expired, he said, and was usually in the top middle drawer in the cart, but instead it was put in the refrigerator. LVN CB said the third shift stocked the med carts. LVN CB said RN/ADON AK said R#42's insulin was in the refrigerator. LVN CB said the insulin was not in the cart as he would have noticed it. LVN CB said he did not know R#432 was diabetic. LVN CB said the diabetic book was part of his orientation and all halls had them. In an interview at 5:45 p.m. on 07/17/18, LVN CR said she worked at the facility since (MONTH) 5, (YEAR). LVN CR said she was oriented on the use of the diabetic book. LVN CR said she assisted R#432 with eating lunch on 07/16/18, just before his FM picked him up from the facility. LVN CR said R#432 tolerated the meal well; when she moved him back in his wheelchair because he was sitting forward, LVN CR made a sighing sound. LVN CR said R#432 ate his food, drank juice, water and milk, and tried to grab liquids. LVN CR said liquids fell out of R#432's mouth as he drank. LVN CR said R#432 drank thickened liquids but she did not remember the texture of his food; he ate more than 80% of his meal, she said. LVN CR said she had no awareness R#432 was on insulin and she never administered medications to him. In an interview at 7:15 p.m. on 07/17/18, LVN A said she kept notes of everything she did during the day at work. She said she remembered that she did not find any insulin in R#432's box of medications that his FM brought from home. LVN A said she remembered that insulin was written on the MAR and she verified these orders with R#432's physician. LVN A said other shifts would have written on the MAR and would have seen it. In an interview at 7:23 p.m. on 07/17/18, RN/ADON AK said she remembered R#432 from a previous admission. RN/ADON AK said after she found out R#432 never received insulin, she noted that the insulin was written near the bottom of the start up orders and was supposed to be transcribed to the diabetic MAR, but it never made it on there. RN/ADON AK said LVN A checked in R#432's medications and she was the admitting nurse. RN/ADON AK said she was notified by LVN AS after she discharged R#432 that she found a vial of insulin and it was expired and it was from (MONTH) (YEAR); that was when everything came to light at the end of the day on 07/16/18. Upon discharge on 07/16/18, RN/ADON AK said she stumbled upon an expired insulin vial in the refrigerator of the med room and she gave it back to FM. RN/ADON AK said she did not know how the insulin ended up in the refrigerator. RN/ADON AK said when a new resident was admitted , she checked the MARS for discrepancies. When asked if she reviewed R#432's MARS for discrepancies, RN/ADON AK said she skimmed over it but did not check the MAR and see that it was transcribed to the diabetic MAR. RN/ADON AK said it looked like a standard admission. RN/ADON AK said she saw that R#432 had insulin listed at the bottom of the start up orders. RN/ADON AK said LVN A had over three days of orientation on the floor, including shadowing another nurse. RN/ADON AK said LVN A had knowledge of the diabetic book, but she got overwhelmed and she forgot a step. RN/ADON AK said no one said they knew who put the insulin in the refrigerator. RN/ADON AK said it was not that unusual that orders were received for giving insulin without doing finger sticks as some physicians did not order accuchecks of blood sugar. RN/ADON AK said she would have expected her 7:00 a.m. to 3:00 p.m. nurses or her night shift to catch that the insulin was not transcribed to the diabetic MAR, and she said she expected more from herself. In an interview at 7:48 p.m. on 07/17/18, LVN A said she verified R#432's orders with a Nurse Practitioner (NP). Regarding the insulin, R#432 was supposed to be given 15 units in the morning and seven units in the evening. LVN A said she would have written in the nurse's notes if she had verified whether the NP wanted finger sticks to be done. LVN A said there was no Policies and Procedures book to look through to see if she did the admission correctly. LVN A said she could not remember if she administered any insulin to R#432. LVN A said she worked for the corporation that owned the facility ten to [AGE] years ago, and did not remember a procedure for a diabetic book. In an interview at 8:11 p.m. on 07/17/18, FM said R#432's blood sugar was at 150 but he was still dehydrated and in ICU at the hospital. FM said she was sure she gave the facility a whole new bottle of insulin when she took R#432 to the facility on [DATE], but she did remember removing the cap. FM said she would check the expiration date of the insulin. In an interview at 9:00 p.m. on 07/17/18, FM said the insulin she took to the facility on [DATE] was filled on 02/14/18 and had an expiration date of 01/2020. The insulin also said to discard the bottle after 02/13/19. FM said she gave the medications to LVN AS (calling her by her first name and describing her) when she took R#432 to the facility on [DATE]. FM said when she picked up R#432 on 07/16/18, she noticed that on the outside of the box of insulin was written in black marker, 03-17-18. FM said currently R#432's blood sugar was down to 115 and his labs were looking good, and the hospital was going to see if he would eat a little bit. In an interview at 9:58 a.m. on 07/18/18, LVN AS said she worked the 7:00 a.m. to 3:00 p.m. shift. LVN AS said she received R#432 alert on the day he came into the facility. LVN AS said she wrote the headers and footers of the admission packets and wrote down his medications but did not write down the times he took them. LVN AS said R#432 got to the facility at 2:45 p.m., and because she got off work at 3:00 p.m., she did not do the admission. LVN AS said she gave the incoming nurse, LVN A, report, and R#432 and FM went straight into the Social Worker's office. LVN AS said on the morning that R#432 was discharged , 07/16/18, LVN R gave her report and told her R#432's insulin was expired and did not need to be on the cart. The date that it was expired was written in black on the side of the insulin box; she looked at the box and it was opened in (MONTH) and did not have an expiration date. LVN AS said she knew it was only good for 28 days. She put it in the refrigerator around 7:00 a.m. on 07/16/18. When R#432 left, she put all of R#432's medications in a bag and gave them to his FM. In the interview at 9:58 a.m. on 07/18/18, LVN AS said she passed medications to R#432 on 07/09/18, 07/10/18, 07/11/18, 07/15/18 and 07/16/18. She said she passed medications to R#432 when he was at the facility before this respite stay, and she now remembered he took insulin before. LVN AS said she probably did see that R#432 had insulin written on the start up orders, and the list of medications came from a fax the facility received from the Veterans Administration with R#432's [DIAGNOSES REDACTED]. LVN AS said she remembered R#432 was supposed to be given insulin around 9:00 p.m. LVN AS said LVN A was new at the facility. LVN AS said if it was her admission, she would have rewritten the start up orders and put an asterisk on them and would have put the insulin on the insulin sheet. The start up orders would have been faxed to the pharmacy. LVN AS said she did not tell LVN A to transcribe to the insulin record. It was automatic, LVN AS said, for RN/ADON AK to review and tell her what need to be corrected on admissions. LVN AS said a resident could die if he missed his insulin for a week. In an interview at 10:30 a.m. on 07/18/18, the DON said she was in the process of ensuring everyone who handled admissions knew the policies and procedures for them. The DON said she did not understand who put the black marker with the date 03-17-18 on R#432's insulin. In an interview on 07/20/18 at 11:00 a.m., LVN R said she got report on 07/09/18 from LVN A. LVN R worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she said she knew she needed to check R#432's blood sugar and said there should have been orders for accuchecks, saying, Yes, absolutely, no doubt about it. In an interview on 07/20/18 at 5:26 p.m., LVN A said that she looked at some notes that she kept at home regarding medications that she gave during her shifts, and she found that she had given seven units of insulin to R#432 once or twice when he was at the facility. She said she also remembered checking his blood sugar once or twice before giving him his insulin. She said she found the insulin in the top drawer of the medication cart. After that, she said she was on vacation. In an interview at 10:55 a.m. on 07/21/18, the DON said each nurse was responsible for ensuring the medications were correct. The DON said it was not the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure the insulin was not expired. In an interview and record review at 12:10 p.m. on 07/21/18, surveyor and LVN AS reviewed LVN AS' written statement regarding the incident with R#432 not receiving insulin. LVN AS had written that it was the 11:00 p.m. to 7:00 a.m. nurse's responsibility to ensure that medication carts were checked, and expired medications pulled out. LVN AS said she used to work the 11:00 p.m. to 7:00 a.m. shift and she provided a copy of instructions that she said she used when she worked the 11:00 p.m. to 7:00 a.m. shift. The instructions were dated 12/27/16 and said the nurse on that shift would replace insulin bottles on the med cart with new insulin bottles, and on the 24th of every month, insulins would be reordered by the 11:00 p.m. to 7:00 a.m. nurse and placed on the cart with the date on the 28th of every month. This will eliminate expired insulins to be on the med cart. On 07/18/18 at 5:58 p.m., the facility Administrator and the DON were notified that an Immediate Jeopardy situation had been identified due to the above failures. On 07/19/18 at 3:00 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The facility's final Plan of Removal documented: A 100% audit of all residents with a [DIAGNOSES REDACTED]. Physician or physician extender to be notified for residents who are discovered to be missing interventions such as FSBS or Lab. To be completed by LVN/ADON AN; LVN AB; LVN/MDS W and SDC/LVN BC/Education Nurse by 7/18/18. All residents with a [DIAGNOSES REDACTED]. By: LVN/ADON AN; LVN AB; LVN/MDS W; LVN DE by 7/19/19. This assessment to include: o

Based on observation, interview, and record review the facility failed to ensure that one Resident (R #432) of five newly admitted residents, who had a [DIAGNOSES REDACTED].#432, R #17, and R #117) of eight residents reviewed for the development of or deterioration of pressure ulcers were free from neglect. The facility did not carry out Physician's O rders to administer R#432's insulin medication. The facility did not follow their procedures for insulin administration by transcribing the physicians orders for insulin to the diabetic MAR (Medication Administration Record) in the diabetic book used by nurses who administered insulin. The facility did not consult with R #432's physician for orders for blood glucose monitoring since R #432 had a [DIAGNOSES REDACTED]. The facility did not follow their processes for newly admitted residents when the Assistant Director of Nurses (ADON) failed to review R#432's admission records for accuracy and for following facility admission procedures. R#432 was transported to the emergency room at a local hospital shortly after being discharged from the facility, and he was admitted to the hospital in the Intensive Care Unit with a blood sugar of 952 and severe dehydration. R#432 also had three Stage 2 pressure ulcers on his buttocks that were not present when he entered the facility. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could affect 44 residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the affects of lack of diabetic monitoring and medication administration. 1.) Resident #432: -The facility failed to assess and document a detailed description of R #432's pressure ulcers upon admission other than he was admitted with a Left Heel stage 3 and a Right Heel Stage 2. -LVN BL failed to consult with R #432's physician when she saw a change in R #432's right heel pressure ulcer, indicating a deterioration. -The facility did not provide R #432 with a second daily treatment on his right heel on [DATE] and [DATE] as prescribed by the physician. -R #432's Baseline Care Plan did not include specific preventative measures/interventions R #432 should have been provided with for off-loading purposes. 2) Resident #17: -The facility did not ensure staff applied moisture barrier cream on R #17 after each incontinent care episode, whom was identified as at risk for pressure ulcer development. -The facility failed to monitor and ensure R #17's low air loss mattress (identified by the facility as being used as a preventative measure to prevent pressure ulcer development) was set at the accurate setting. R #17's mattress was set at 400 pounds however, R #17 weighed 94 pounds. -CNAs Z and AX did not identify or report that R #17 had an open area on her sacrum, after providing her incontinent care. After the surveyor's inquiry, the facility identified R #17's open area as a Stage 2 pressure ulcer. 3) Resident #117: -The facility failed to ensure that R #117 was repositioned every two hours as indicated in her care plan. R #117 layed in the same position for over three hours. -CNAs Z and AX did not identify or report that R #117 had an open area on her right hip and purple discoloration to her left lateral great toe, after providing her incontinent care and repositioning. R #117 developed a facility acquired Stage 2 pressure ulcer to her right hip and a Deep Tissue Injury to her left lateral great toe and the facility was not aware until the surveyor's inquiry. The findings included: The facility's Abuse - Reportable Events Policy and Procedure dated ,[DATE] documented Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of the Face Sheet dated [DATE] revealed R#432 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R#432 was [AGE] years old and entered the facility under a Veteran's Administration respite care stay. The face sheet said he would discharge on [DATE]. A Minimum Data Set (MDS) for the respite care stay beginning [DATE] was not found in the chart or on the facility computerized documentation system. Review of the Start Up Orders for R#432 revealed DM (Diabetes Mellitus) as the first [DIAGNOSES REDACTED].@ (at) HS (night). A Multi-vitamin with minerals was also listed to be taken daily due to a [DIAGNOSES REDACTED]. In addition to the insulin and multivitamin with minerals, medications listed were Asa 81 mg daily; [MEDICATION NAME] 5 mg BID (twice daily); Vitamin D3 BID; Donepezil Hcl 5 mg @ HS; Magnesium [MEDICATION NAME] liquid, take one-half of a bottle as needed; [MEDICATION NAME] 20 mg HS; [MEDICATION NAME] Hcl 150 mg BID; Tamsulosin Hcl (unable to read the strength) HS; [MEDICATION NAME] Hcl (unable to read the strength); Atorvastatin Calcium 10 mg give ½ tab QHS; and [MEDICATION NAME] one capful in eight ounces of juice daily. The orders were signed by Licensed Vocational Nurse (LVN) A on [DATE]. Review of Start Up Orders Medication Administration Record revealed no insulin had been given from [DATE] through [DATE]. No multivitamin with minerals had been given. All other medications were given as ordered by the physician. Review of Admission Data Summary dated [DATE] revealed R#432 was admitted to the facility for a respite stay. His ADL (Activities of Daily Living) function prior to admission was that he required the assistance of one for mobility and transfer; required some assistance/cueing with eating; was incontinent of bowel and bladder and had some communication difficulty with finding words or finishing thoughts. Medications were not listed, and see attached was written in their place. R#432 had an unstable gait, weakness, was confused, disoriented or hallucinating. He had short-term and long-term memory problems but could usually understand others and make himself understood. R#432 was not in pain. R#432 was not at risk for wandering. He was at risk for weight loss due to chewing/swallowing problems. R#432 had moderately to severely impaired cognition and weakness in his upper extremities. R#432 had a Stage III pressure ulcer on his left heel, .5 X .5 X .2; and on his right heel he had a red area, Stage II pressure ulcer, 1.8 X 1.5. The Admission Data Summary dated [DATE] indicated R#432 was Diabetic and had [MEDICAL CONDITIONS]. He had some foot problems, open [MEDICAL CONDITION] on his foot and required application of dressings. Review of R#432's Baseline Care Plan dated [DATE], completed by LVN A, revealed he had some current pressure injury, and should be turned every two hours and prn, and to follow facility skin care guidelines. R#432 was also diabetic and the care plan indicated Medications as ordered; diet as ordered; observe for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The Physician order [REDACTED]. Review of closed records revealed R#432 had been at the facility for previous respite care stays, from [DATE] to [DATE], and again from [DATE] to [DATE]. R#432 had physician orders [REDACTED]. On initial tour of the facility on [DATE] at 10:23 a.m., R#432 was not in his room. At 4:15 p.m. on [DATE], the ADON said R#432 had been at the facility on a respite stay and had been picked up by a family member early in the afternoon of [DATE]. Review of emergency room (ER) records dated [DATE] at 3:17 p.m. revealed R#432 was alert, disoriented times three, lethargic, and would follow commands but would not respond when asked questions. He was picked up from a nursing home and looked dehydrated. The chief complaint was altered mental status. FM came in with him and said he was not responding to her as he was complaining of pain but unable to tell her where he was hurting. FM said he would normally converse without any issue, though he did have some early dementia, but he had never been this altered. Associated symptoms were less active, weakness. Review of the ER Physician's Examination on [DATE] at 4:37 p.m. revealed R#432's vital signs were within normal limits with the exception of his heart rate which was 114. R#432 looked severely malnourished, dehydrated with dry mucous membranes, and was found to have a sugar greater than what our machine reads in triage therefore he was urgently moved back to room [ROOM NUMBER] for evaluation. History is provided mostly by family as the patient does not speak. The ER physician further commented that R#432 was found to have a sugar of 952 in triage; IV fluids and an insulin drip were started. R#432's corrected sodium was 176. He will be admitted to ICU. In an interview at 11:30 a.m. on [DATE], the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) DE fed R#432 lunch on [DATE], and R#432's Family Member (FM) picked him up around 2:00 p.m. on [DATE]. The DON said R#432's FM called her on [DATE], and said that she took R#432 to the hospital after picking him up at the facility and he was admitted to ICU with a blood sugar of 952. The DON said she reviewed R#432's chart and found that there were no treatment records. The DON pointed at R#432's admitting physician's orders [REDACTED].#432 and no orders for doing finger sticks. The DON said she suspended the admitting nurse because the admitting nurse did not transcribe the insulin order to the diabetic or finger stick MARS. The DON said, What we have is a multi-system failure here. The DON said she had only been at the facility a few days, with a start date of [DATE], and she was just starting to look at the processes and concerns of the facility and was not aware of any concerns regarding R#432 until she received a call from his FM on [DATE]. The DON said the processes for admissions had not been followed. The DON said charts were not reviewed in the morning meeting, and they should have been reviewed. The DON said she reviewed new admissions daily. The DON said the facility began reviewing any residents who had codes for diabetes (on their MDS) and reviewed their medication cart-to-MAR-to-Physician order [REDACTED].#432 was a new resident. The DON said the admitting nurse should have called and gotten orders from the physician for finger sticks. In the interview at 11:30 a.m. on [DATE], surveyor asked the DON what the complications of missing 14 insulin doses, the number of doses of insulin missed by R#432, would be; the DON responded that the resident could go into a coma, die or have a [MEDICAL CONDITION], and said It's a big danger. When asked what Policies and Procedures (P and P's) were in place regarding admissions and treatments, the DON responded that she did not know since she had been at the facility such a short time and had not gotten involved with the P and P's yet. In the interview at 11:30 a.m. on [DATE], the DON said the nurse who discharged R#432 discharged him with an insulin vial that expired in (MONTH) (YEAR). The LVN who discharged him, the DON said, did not seem to think anything of that. In an interview at 2:03 p.m. on [DATE], R#432's FM said she was R#432's caregiver and he lived with her. FM said R#432 had two [MEDICAL CONDITION] and a [MEDICAL CONDITION] in (YEAR). FM said R#432 was able to talk to her a little bit but had dementia and could not talk very much. R#432 was paralyzed on his left side and used a wheelchair; FM said R#432 needed help to eat, his food was a chopped texture and his drinks were nectar thick. FM said R#432's blood sugars ran 180 or 190. FM said she gave R#432 his morning insulin injection on [DATE] before she took him to the facility and thought his blood sugar was 160 at that time. FM said she checked R#432's blood sugar three times a day; before breakfast, before lunch and before dinner. R#432 said the Veterans Administration allowed respite care for R#432 for up to 30 days a year. FM said she and her family went out of town while R#432 was at the facility. FM said R#432 had been to the facility for respite three or four times and this stay from [DATE] to [DATE] completed his 30 days of respite that he was allowed for the year. FM said R#432 was a very good eater. In the interview at 2:03 p.m. on [DATE], FM said she gave R#432's medication to the facility when he was admitted . FM said R#432 had a mood disorder medication, Tamsulosin for his prostate; two vitamins in the morning; a heart pill twice daily; and insulin. FM said she took a brand-new bottle of insulin to the facility and it was not given during his stay there that she could tell. FM said the VA sent R#432 a new bottle of insulin about a month and a half ago. FM said she had removed the cap from the bottle of insulin. FM said the facility called her on Friday, [DATE], to come pick up R#432, but she said that the respite care was supposed to last until [DATE], and the facility agreed to keep him there until [DATE]. In the interview at 2:03 p.m. on [DATE], FM said she called and spoke to LVN AS on [DATE] to see how R#432 was doing. LVN AS said R#432 was doing good, sitting at the nurse's station. FM said she told LVN AS that she would be at the facility shortly to pick R#432 up. FM said that when she went to pick up R#432 about 2:00 p.m. on [DATE], she found R#432 in his room. FM said R#432's eyes were sunken in and he looked ten pounds lighter. FM said she went to the nurse's station and asked how R#432 had been eating, and said that R#432 looked sick, eyes sunken in and he looked skinny. LVN AS was not there as she was getting his medication. The people at the nurse's station said R#432 was eating 75% of his food and was on nectar liquids. FM said she signed R#432's discharge papers and after taking him out of the facility, she decided to take R#432 to the emergency room . FM said R#432's tongue was sticking out and he was not able to respond. R#432's arms were shaking and when she asked if he was ok, he gave no response. FM said after waiting one and one-half hours at the emergency room (ER), R#432 was taken back to a room and blood work was initiated. FM said about 5:30 p.m. on [DATE], she was told R#432 had high blood sugar that was so high their monitor could not read it. The ER later determined R#432's blood sugar was 952 and his sodium level was 169. FM said she called the facility and spoke to the DON on [DATE] to find out what was going on with R#432, and at about 6:00 p.m. or 6:30 p.m., she was told the facility never gave R#432 his insulin. FM said in the morning of [DATE], she received a call from an ICU nurse that R#432 was severely dehydrated and had three open sores on his bottom. FM said she told the Administrator that R#432 went in with a pressure ulcer on his left heel that was in the process of healing and he did not have pressure ulcers on his bottom. FM said when she picked up R#432 from the facility, the pressure ulcer on his left heel was open and draining. FM said R#432's blood sugar had been responding to his care at the hospital and was 191 about an hour ago. FM said R#432 was still hallucinating and very confused. FM said she was angry because the facility never notified her of any problems with R#432's insulin, and he was also crying because the ulcers on his bottom were hurting him. FM said, I left him there so that they could take care of him and I came home, and he was dying. FM said R#432 raised her and she has been taking care of him since (YEAR). In an interview at 3:06 p.m. on [DATE], LVN P said she did not remember anything regarding medication administration for R#432. LVN P said R#432 was alert, up in a wheelchair with assistance, and needed total care. LVN P said she did not remember whether R#432 required finger sticks or insulin and said it would help if she could look at the finger stick book. LVN P said if R#432 was no longer at the facility, insulin that was given would only be documented in the finger stick book. LVN P said the handwritten MAR-finger stick book was on the medication cart. LVN P reviewed R#432's startup orders, which had medications listed and initials for medications that were administered. LVN P said she recognized her signature on the start up orders and said she did not recall seeing an order for [REDACTED]. LVN P said if she had seen the order for insulin, she would have written out a page for his diabetes and would have put it in the finger stick book. When asked what a nurse should do if there were no orders for checking blood sugars for an insulin dependent diabetic, LVN P answered that they were supposed to have finger sticks so that blood sugars could be tracked. LVN P said she did not see orders for finger sticks on R#432's start up orders. LVN P said it was everyone's responsibility if they took care of R#432 to follow up on insulin/finger stick orders. In the interview at 3:06 p.m. on [DATE], LVN P said the admitting nurse would write all medications down on the start up orders and then complete the Diabetic Flow Sheet and put it in the diabetic book. LVN P said the insulin column on the start up orders was blank; she said she would wonder if it was ever given and would call the doctor. LVN P said finger sticks and insulin were never documented on the startup MAR and were always documented on the diabetic book. In an interview at 3:41 p.m. on [DATE], the DON said she looked through the finger stick/diabetic book twice after she was called by R#432's FM on [DATE], and she did not find anything regarding R#432's finger stick or insulin. The DON confirmed R #432 did not have oders for blood glucose monitoring. The DON said the nurses, any nurse involved with R #432's care, should have identified that there were no fingerstick orders and should have called the physician to get orders since R #432 was a diabetic and was prescribed daily insulin administration. The DON stated the importance of fingersticks was to monitor and track the residents blood glucose levels and evaluate whether his prescribed insulin was effective. The DON said if the blood glucose level was not known, administration of the prescribed insulin could cause [DIAGNOSES REDACTED] (low blood sugar) placing the resident at risk for coma and/or death. The DON further explained that if the blood glucose level was not known, the resident's blood sugar to be too high and potentially cause coma or death. In an interview at 4:47 p.m. on [DATE], LVN A said she admitted R#432 on [DATE]. LVN A said she had three days of orientation and the orientation did not include the admission process. LVN A said it was only the second admission she had done, and she asked LVN AS and RN/ADON AK to review the admission for R#432 because she wanted to be sure it was done correctly. LVN A said the next day she asked RN/ADON AK if she had completed R#432's admission correctly, and RN/ADON AK responded that she had not reviewed it but from what she knew it was done okay and she would look at it. LVN A said she did a head to toe assessment of R#432, looked at his medications from home and compared them to what the physician ordered. LVN A said the medications brought in by R#432's FM were in a little box; she said insulin was in the little box and was written on the startup orders. LVN A said the medications were already written out by LVN AS on R#432's start up orders when she proceeded with his admission, and R#432 had already arrived at the facility. LVN A said she reviewed the medications with the Nurse Practitioner who oversaw R#432's care at the facility, and she crossed out four medications and wrote error because they were no longer being ordered. In the interview on [DATE] at 4:47 p.m., LVN A said she was a relief worker and did not know the facility procedure of transcribing insulin and finger stick orders to the Diabetic MAR and putting it in the diabetic book. LVN A said she did not notice that there was no order for finger sticks for R#432 but she knew as a nurse that they should have been done. In an interview at 5:08 p.m. on [DATE], LVN R said she worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she remembered R#432 and said, He's diabetic. I checked his sugar when he was here before. He was here for respite. I saw insulin in the med cart. There was no paper for him in the diabetic book, so I thought, Okay, I guess we don't check his sugar. Why did they bring his insulin? LVN R said there were things marked out on the MAR and she did not see any time on the startup orders for insulin to be given. LVN R said, A lot of us missed it. Where's the sheet? All diabetic stuff goes on one sheet. LVN R said she told LVN AS, who worked 7:00 a.m. to 3:00 p.m., that she (LVN R) was wondering why they were not checking his sugar. LVN R said LVN AS said she wondered the same thing. Surveyor asked LVN R if she called R#432's physician to clarify whether insulin should be given to him, and she replied she did not call the physician because he could not practice any longer (surveyor was later advised that LVN R was mistaken). Surveyor asked LVN R if she notified her supervisor that there were concerns regarding R#432's insulin administration, and she replied that she answered to RN/ADON AK and she did not inform RN/ADON AK. LVN R said she overlooked doing that. LVN R said she should have notified someone. LVN R said they also missed administering R#432's Vitamins with minerals. When asked what the possible consequences were of not giving insulin to a diabetic when it was ordered, LVN R responded that the resident could go into a coma, go to the hospital or die from it. In an interview at 5:22 p.m. on [DATE], LVN CB said he worked at the facility since the end of (MONTH) (YEAR). LVN CB said R#432's orders were never transcribed to his MAR. LVN CB said R#432's startup orders were confusing to pass medications, with marks through some of the medications and other things changed. LVN CB said the insulin and minerals were at the bottom of the start up orders. He said they should have put the hours for the insulin to be given in the column next to the medication. LVN CB said insulin should have been given at 7:00 in the morning and the minerals should have been given daily. LVN CB said no doses of insulin were given and normally there should be an insulin flow sheet, but R#432 did not have anything in the diabetic flow book. LVN CB said R#432 did not have insulin in the med cart. The insulin was expired, he said, and was usually in the top middle drawer in the cart, but instead it was put in the refrigerator. LVN CB said the third shift stocked the med carts. LVN CB said RN/ADON AK said R#42's insulin was in the refrigerator. LVN CB said the insulin was not in the cart as he would have noticed it. LVN CB said he did not know R#432 was diabetic. LVN CB said the diabetic book was part of his orientation and all halls had them. In an interview at 5:45 p.m. on [DATE], LVN CR said she worked at the facility since (MONTH) 5, (YEAR). LVN CR said she was oriented on the use of the diabetic book. LVN CR said she assisted R#432 with eating lunch on [DATE], just before his FM picked him up from the facility. LVN CR said R#432 tolerated the meal well; when she moved him back in his wheelchair because he was sitting forward, LVN CR made a sighing sound. LVN CR said R#432 ate his food, drank juice, water and milk, and tried to grab liquids. LVN CR said liquids fell out of R#432's mouth as he drank. LVN CR said R#432 drank thickened liquids but she did not remember the texture of his food; he ate more than 80% of his meal, she said. LVN CR said she had no awareness R#432 was on insulin and she never administered medications to him. In an interview at 7:15 p.m. on [DATE], LVN A said she kept notes of everything she did during the day at work. She said she remembered that she did not find any insulin in R#432's box of medications that his FM brought from home. LVN A said she remembered that insulin was written on the MAR and she verified these orders with R#432's physician. LVN A said other shifts would have written on the MAR and would have seen it. In an interview at 7:23 p.m. on [DATE], RN/ADON AK said she remembered R#432 from a previous admission. RN/ADON AK said after she found out R#432 never received insulin, she noted that the insulin was written near the bottom of the start up orders and was supposed to be transcribed to the diabetic MAR, but it never made it on there. RN/ADON AK said LVN A checked in R#432's medications and she was the admitting nurse. RN/ADON AK said she was notified by LVN AS after she discharged R#432 that she found a vial of insulin and it was expired and it was from (MONTH) (YEAR); that was when everything came to light at the end of the day on [DATE]. Upon discharge on [DATE], RN/ADON AK said she stumbled upon an expired insulin vial in the refrigerator of the med room and she gave it back to FM. RN/ADON AK said she did not know how the insulin ended up in the refrigerator. RN/ADON AK said when a new resident was admitted , she checked the MARS for discrepancies. When asked if she reviewed R#432's MARS for discrepancies, RN/ADON AK said she skimmed over it but did not check the MAR and see that it was transcribed to the diabetic MAR. RN/ADON AK said it looked like a standard admission. RN/ADON AK said she saw that R#432 had insulin listed at the bottom of the start up orders. RN/ADON AK said LVN A had over three days of orientation on the floor, including shadowing another nurse. RN/ADON AK said LVN A had knowledge of the diabetic book, but she got overwhelmed and she forgot a step. RN/ADON AK said no one said they knew who put the insulin in the refrigerator. RN/ADON AK said it was not that unusual that orders were received for giving insulin without doing finger sticks as some physicians did not order accuchecks of blood sugar. RN/ADON AK said she would have expected her 7:00 a.m. to 3:00 p.m. nurses or her night shift to catch that the insulin was not transcribed to the diabetic MAR, and she said she expected more from herself. In an interview at 7:48 p.m. on [DATE], LVN A said she verified R#432's orders with a Nurse Practitioner (NP). Regarding the insulin, R#432 was supposed to be given 15 units in the morning and seven units in the evening. LVN A said she would have written in the nurse's notes if she had verified whether the NP wanted finger sticks to be done. LVN A said there was no Policies and Procedures book to look through to see if she did the admission correctly. LVN A said she could not remember if she administered any insulin to R#432. LVN A said she worked for the corporation that owned the facility ten to [AGE] years ago, and did not remember a procedure for a diabetic book. In an interview at 8:11 p.m. on [DATE], FM said R#432's blood sugar was at 150 but he was still dehydrated and in ICU at the hospital. FM said she was sure she gave the facility a whole new bottle of insulin when she took R#432 to the facility on [DATE], but she did remember removing the cap. FM said she would check the expiration date of the insulin. In an interview at 9:00 p.m. on [DATE], FM said the insulin she took to the facility on [DATE] was filled on [DATE] and had an expiration date of ,[DATE]. The insulin also said to discard the bottle after [DATE]. FM said she gave the medications to LVN AS (calling her by her first name and describing her) when she took R#432 to the facility on [DATE]. FM said when she picked up R#432 on [DATE], she noticed that on the outside of the box of insulin was written in black marker, [DATE]. FM said currently R#432's blood sugar was down to 115 and his labs were looking good, and the hospital was going to see if he would eat a little bit. In an interview at 9:58 a.m. on [DATE], LVN AS said she worked the 7:00 a.m. to 3:00 p.m. shift. LVN AS said she received R#432 alert on the day he came into the facility. LVN AS said she wrote the headers and footers of the admission packets and wrote down his medications but did not write down the times he took them. LVN AS said R#432 got to the facility at 2:45 p.m., and because she got off work at 3:00 p.m., she did not do the admission. LVN AS said she gave the incoming nurse, LVN A, report, and R#432 and FM went straight into the Social Worker's office. LVN AS said on the morning that R#432 was discharged , [DATE], LVN R gave her report and told her R#432's insulin was expired and did not need to be on the cart. The date that it was expired was written in black on the side of the insulin box; she looked at the box and it was opened in (MONTH) and did not have an expiration date. LVN AS said she knew it was only good for 28 days. She put it in the refrigerator around 7:00 a.m. on [DATE]. When R#432 left, she put all of R#432's medications in a bag and gave them to his FM. In the interview at 9:58 a.m. on [DATE], LVN AS said she passed medications to R#432 on [DATE], [DATE], [DATE], [DATE] and [DATE]. She said she passed medications to R#432 when he was at the facility before this respite stay, and she now remembered he took insulin before. LVN AS said she probably did see that R#432 had insulin written on the start up orders, and the list of medications came from a fax the facility received from the Veterans Administration with R#432's [DIAGNOSES REDACTED]. LVN AS said she remembered R#432 was supposed to be given insulin around 9:00 p.m. LVN AS said LVN A was new at the facility. LVN AS said if it was her admission, she would have rewritten the start up orders and put an asterisk on them and would have put the insulin on the insulin sheet. The start up orders would have been faxed to the pharmacy. LVN AS said she did not tell LVN A to transcribe to the insulin record. It was automatic, LVN AS said, for RN/ADON AK to review and tell her what need to be corrected on admissions. LVN AS said a resident could die if he missed his insulin for a week. In an interview at 10:30 a.m. on [DATE], the DON said she was in the process of ensuring everyone who handled admissions knew the policies and procedures for them. The DON said she did not understand who put the black marker with the date [DATE] on R#432's insulin. In an interview on [DATE] at 11:00 a.m., LVN R said she got report on [DATE] from LVN A. LVN R worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she said she knew she needed to check R#432's blood sugar and said there should have been orders for accuchecks, saying, Yes, absolutely, no doubt about it. In an interview on [DATE] at 5:26 p.m., LVN A said that she looked at some notes that she kept at home regarding medications that she gave

Based on observation, interview, and record review the facility failed to ensure that one Resident (R #432) of five newly admitted residents, who had a [DIAGNOSES REDACTED].#432, R #17, and R #117) of eight residents reviewed for the development of or deterioration of pressure ulcers were free from neglect. The facility did not carry out physician's orders [REDACTED]. The facility did not follow their procedures for insulin administration by transcribing the physicians orders for insulin to the diabetic MAR (Medication Administration Record) in the diabetic book used by nurses who administered insulin. The facility did not consult with R #432's physician for orders for blood glucose monitoring since R #432 had a [DIAGNOSES REDACTED]. The facility did not follow their processes for newly admitted residents when the Assistant Director of Nurses (ADON) failed to review R#432's admission records for accuracy and for following facility admission procedures. R#432 was transported to the emergency room at a local hospital shortly after being discharged from the facility, and he was admitted to the hospital in the Intensive Care Unit with a blood sugar of 952 and severe dehydration. R#432 also had three Stage 2 pressure ulcers on his buttocks that were not present when he entered the facility. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could affect 44 residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the affects of lack of diabetic monitoring and medication administration. 1.) Resident #432: -The facility failed to assess and document a detailed description of R #432's pressure ulcers upon admission other than he was admitted with a Left Heel stage 3 and a Right Heel Stage 2. -LVN BL failed to consult with R #432's physician when she saw a change in R #432's right heel pressure ulcer, indicating a deterioration. -The facility did not provide R #432 with a second daily treatment on his right heel on [DATE] and [DATE] as prescribed by the physician. -R #432's Baseline Care Plan did not include specific preventative measures/interventions R #432 should have been provided with for off-loading purposes. 2) Resident #17: -The facility did not ensure staff applied moisture barrier cream on R #17 after each incontinent care episode, whom was identified as at risk for pressure ulcer development. -The facility failed to monitor and ensure R #17's low air loss mattress (identified by the facility as being used as a preventative measure to prevent pressure ulcer development) was set at the accurate setting. R #17's mattress was set at 400 pounds however, R #17 weighed 94 pounds. -CNAs Z and AX did not identify or report that R #17 had an open area on her sacrum, after providing her incontinent care. After the surveyor's inquiry, the facility identified R #17's open area as a Stage 2 pressure ulcer. 3) Resident #117: -The facility failed to ensure that R #117 was repositioned every two hours as indicated in her care plan. R #117 layed in the same position for over three hours. -CNAs Z and AX did not identify or report that R #117 had an open area on her right hip and purple discoloration to her left lateral great toe, after providing her incontinent care and repositioning. R #117 developed a facility acquired Stage 2 pressure ulcer to her right hip and a Deep Tissue Injury to her left lateral great toe and the facility was not aware until the surveyor's inquiry. The findings included: Review of the Face Sheet dated [DATE] revealed R#432 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R#432 was [AGE] years old and entered the facility under a Veteran's Administration respite care stay. The face sheet said he would discharge on [DATE]. A Minimum Data Set (MDS) for R#432's respite care stay beginning [DATE] was not found in the chart or on the facility computerized documentation system. Review of the Start Up Orders for R#432 revealed DM (Diabetes Mellitus) as the first [DIAGNOSES REDACTED].@ (at) HS (night). A Multi-vitamin with minerals was also listed to be taken daily due to a [DIAGNOSES REDACTED]. In addition to the insulin and multivitamin with minerals, medications listed were Asa 81 mg daily; [MEDICATION NAME] 5 mg BID (twice daily); Vitamin D3 BID; Donepezil Hcl 5 mg @ HS; Magnesium [MEDICATION NAME] liquid, take one-half of a bottle as needed; [MEDICATION NAME] 20 mg HS; [MEDICATION NAME] Hcl 150 mg BID; Tamsulosin Hcl (unable to read the strength) HS; [MEDICATION NAME] Hcl (unable to read the strength); Atorvastatin Calcium 10 mg give ½ tab QHS; and [MEDICATION NAME] one capful in eight ounces of juice daily. The orders were signed by Licensed Vocational Nurse (LVN) A on [DATE]. Review of Start Up Orders Medication Administration Record revealed no insulin had been given from [DATE] through [DATE]. No multivitamin with minerals had been given. All other medications were given as ordered by the physician. Review of Admission Data Summary dated [DATE] revealed R#432 was admitted to the facility for a respite stay. His ADL (Activities of Daily Living) function prior to admission was that he required the assistance of one for mobility and transfer; required some assistance/cueing with eating; was incontinent of bowel and bladder and had some communication difficulty with finding words or finishing thoughts. Medications were not listed, and see attached was written in their place. R#432 had an unstable gait, weakness, was confused, disoriented or hallucinating. He had short-term and long-term memory problems but could usually understand others and make himself understood. R#432 was not in pain. R#432 was not at risk for wandering. He was at risk for weight loss due to chewing/swallowing problems. R#432 had moderately to severely impaired cognition and weakness in his upper extremities. R#432 had a Stage III pressure ulcer on his left heel, .5 X .5 X .2; and on his right heel he had a red area, Stage II pressure ulcer, 1.8 X 1.5. The Admission Data Summary dated [DATE] indicated R#432 was Diabetic and had [MEDICAL CONDITIONS]. He had some foot problems, open [MEDICAL CONDITION] on his foot and required application of dressings. Review of R#432's Baseline Care Plan dated [DATE], completed by LVN A, revealed he had some current pressure injury, and should be turned every two hours and prn, and to follow facility skin care guidelines. R#432 was also diabetic and the care plan indicated Medications as ordered; diet as ordered; observe for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The Physician order [REDACTED]. Review of closed records revealed R#432 had been at the facility for previous respite care stays, from [DATE] to [DATE], and again from [DATE] to [DATE]. R#432 had physician orders [REDACTED]. On initial tour of the facility on [DATE] at 10:23 a.m., R#432 was not in his room. At 4:15 p.m. on [DATE], the ADON said R#432 had been at the facility on a respite stay and had been picked up by a family member early in the afternoon of [DATE]. Review of emergency room (ER) records dated [DATE] at 3:17 p.m. revealed R#432 was alert, disoriented times three, lethargic, and would follow commands but would not respond when asked questions. He was picked up from a nursing home and looked dehydrated. The chief complaint was altered mental status. FM came in with him and said he was not responding to her as he was complaining of pain but unable to tell her where he was hurting. FM said he would normally converse without any issue, though he did have some early dementia, but he had never been this altered. Associated symptoms were less active, weakness. Review of the ER Physician's Examination on [DATE] at 4:37 p.m. revealed R#432's vital signs were within normal limits with the exception of his heart rate which was 114. R#432 looked severely malnourished, dehydrated with dry mucous membranes, and was found to have a sugar greater than what our machine reads in triage therefore he was urgently moved back to room [ROOM NUMBER] for evaluation. History is provided mostly by family as the patient does not speak. The ER physician further commented that R#432 was found to have a sugar of 952 in triage; IV fluids and an insulin drip were started. R#432's corrected sodium was 176. He will be admitted to ICU. In an interview at 11:30 a.m. on [DATE], the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) DE fed R#432 lunch on [DATE], and R#432's Family Member (FM) picked him up around 2:00 p.m. on [DATE]. The DON said R#432's FM called her on [DATE], and said that she took R#432 to the hospital after picking him up at the facility and he was admitted to ICU with a blood sugar of 952. The DON said she reviewed R#432's chart and found that there were no treatment records. The DON pointed at R#432's admitting physician's orders [REDACTED].#432 and no orders for doing finger sticks. The DON said she suspended the admitting nurse because the admitting nurse did not transcribe the insulin order to the diabetic or finger stick MARS. The DON said, What we have is a multi-system failure here. The DON said she had only been at the facility a few days, with a start date of [DATE], and she was just starting to look at the processes and concerns of the facility and was not aware of any concerns regarding R#432 until she received a call from his FM on [DATE]. The DON said the processes for admissions had not been followed. The DON said charts were not reviewed in the morning meeting, and they should have been reviewed. The DON said she reviewed new admissions daily. The DON said the facility began reviewing any residents who had codes for diabetes (on their MDS) and reviewed their medication cart-to-MAR-to-Physician order [REDACTED].#432 was a new resident. The DON said the admitting nurse should have called and gotten orders from the physician for finger sticks. In the interview at 11:30 a.m. on [DATE], surveyor asked the DON what the complications of missing 14 insulin doses, the number of doses of insulin missed by R#432, would be; the DON responded that the resident could go into a coma, die or have a [MEDICAL CONDITION], and said It's a big danger. When asked what Policies and Procedures (P and P's) were in place regarding admissions and treatments, the DON responded that she did not know since she had been at the facility such a short time and had not gotten involved with the P and P's yet. In the interview at 11:30 a.m. on [DATE], the DON said the nurse who discharged R#432 discharged him with an insulin vial that expired in (MONTH) (YEAR). The LVN who discharged him, the DON said, did not seem to think anything of that. In an interview at 2:03 p.m. on [DATE], R#432's FM said she was R#432's caregiver and he lived with her. FM said R#432 had two [MEDICAL CONDITION] and a [MEDICAL CONDITION] in (YEAR). FM said R#432 was able to talk to her a little bit but had dementia and could not talk very much. R#432 was paralyzed on his left side and used a wheelchair; FM said R#432 needed help to eat, his food was a chopped texture and his drinks were nectar thick. FM said R#432's blood sugars ran 180 or 190. FM said she gave R#432 his morning insulin injection on [DATE] before she took him to the facility and thought his blood sugar was 160 at that time. FM said she checked R#432's blood sugar three times a day; before breakfast, before lunch and before dinner. R#432 said the Veterans Administration allowed respite care for R#432 for up to 30 days a year. FM said she and her family went out of town while R#432 was at the facility. FM said R#432 had been to the facility for respite three or four times and this stay from [DATE] to [DATE] completed his 30 days of respite that he was allowed for the year. FM said R#432 was a very good eater. In the interview at 2:03 p.m. on [DATE], FM said she gave R#432's medication to the facility when he was admitted . FM said R#432 had a mood disorder medication, Tamsulosin for his prostate; two vitamins in the morning; a heart pill twice daily; and insulin. FM said she took a brand-new bottle of insulin to the facility and it was not given during his stay there that she could tell. FM said the VA sent R#432 a new bottle of insulin about a month and a half ago. FM said she had removed the cap from the bottle of insulin. FM said the facility called her on Friday, [DATE], to come pick up R#432, but she said that the respite care was supposed to last until [DATE], and the facility agreed to keep him there until [DATE]. In the interview at 2:03 p.m. on [DATE], FM said she called and spoke to LVN AS on [DATE] to see how R#432 was doing. LVN AS said R#432 was doing good, sitting at the nurse's station. FM said she told LVN AS that she would be at the facility shortly to pick R#432 up. FM said that when she went to pick up R#432 about 2:00 p.m. on [DATE], she found R#432 in his room. FM said R#432's eyes were sunken in and he looked ten pounds lighter. FM said she went to the nurse's station and asked how R#432 had been eating, and said that R#432 looked sick, eyes sunken in and he looked skinny. LVN AS was not there as she was getting his medication. The people at the nurse's station said R#432 was eating 75% of his food and was on nectar liquids. FM said she signed R#432's discharge papers and after taking him out of the facility, she decided to take R#432 to the emergency room . FM said R#432's tongue was sticking out and he was not able to respond. R#432's arms were shaking and when she asked if he was ok, he gave no response. FM said after waiting one and one-half hours at the emergency room (ER), R#432 was taken back to a room and blood work was initiated. FM said about 5:30 p.m. on [DATE], she was told R#432 had high blood sugar that was so high their monitor could not read it. The ER later determined R#432's blood sugar was 952 and his sodium level was 169. FM said she called the facility and spoke to the DON on [DATE] to find out what was going on with R#432, and at about 6:00 p.m. or 6:30 p.m., she was told the facility never gave R#432 his insulin. FM said in the morning of [DATE], she received a call from an ICU nurse that R#432 was severely dehydrated and had three open sores on his bottom. FM said she told the Administrator that R#432 went in with a pressure ulcer on his left heel that was in the process of healing and he did not have pressure ulcers on his bottom. FM said when she picked up R#432 from the facility, the pressure ulcer on his left heel was open and draining. FM said R#432's blood sugar had been responding to his care at the hospital and was 191 about an hour ago. FM said R#432 was still hallucinating and very confused. FM said she was angry because the facility never notified her of any problems with R#432's insulin, and he was also crying because the ulcers on his bottom were hurting him. FM said, I left him there so that they could take care of him and I came home, and he was dying. FM said R#432 raised her and she has been taking care of him since (YEAR). In an interview at 3:06 p.m. on [DATE], LVN P said she did not remember anything regarding medication administration for R#432. LVN P said R#432 was alert, up in a wheelchair with assistance, and needed total care. LVN P said she did not remember whether R#432 required finger sticks or insulin and said it would help if she could look at the finger stick book. LVN P said if R#432 was no longer at the facility, insulin that was given would only be documented in the finger stick book. LVN P said the handwritten MAR-finger stick book was on the medication cart. LVN P reviewed R#432's startup orders, which had medications listed and initials for medications that were administered. LVN P said she recognized her signature on the start up orders and said she did not recall seeing an order for [REDACTED]. LVN P said if she had seen the order for insulin, she would have written out a page for his diabetes and would have put it in the finger stick book. When asked what a nurse should do if there were no orders for checking blood sugars for an insulin dependent diabetic, LVN P answered that they were supposed to have finger sticks so that blood sugars could be tracked. LVN P said she did not see orders for finger sticks on R#432's start up orders. LVN P said it was everyone's responsibility if they took care of R#432 to follow up on insulin/finger stick orders. In the interview at 3:06 p.m. on [DATE], LVN P said the admitting nurse would write all medications down on the start up orders and then complete the Diabetic Flow Sheet and put it in the diabetic book. LVN P said the insulin column on the start up orders was blank; she said she would wonder if it was ever given and would call the doctor. LVN P said finger sticks and insulin were never documented on the startup MAR and were always documented on the diabetic book. In an interview at 3:41 p.m. on [DATE], the DON said she looked through the finger stick/diabetic book twice after she was called by R#432's FM on [DATE], and she did not find anything regarding R#432's finger stick or insulin. The DON confirmed R #432 did not have oders for blood glucose monitoring. The DON said the nurses, any nurse involved with R #432's care, should have identified that there were no fingerstick orders and should have called the physician to get orders since R #432 was a diabetic and was prescribed daily insulin administration. The DON stated the importance of fingersticks was to monitor and track the residents blood glucose levels and evaluate whether his prescribed insulin was effective. The DON said if the blood glucose level was not known, administration of the prescribed insulin could cause [DIAGNOSES REDACTED] (low blood sugar) placing the resident at risk for coma and/or death. The DON further explained that if the blood glucose level was not known, the resident's blood sugar to be too high and potentially cause coma or death. In an interview at 4:47 p.m. on [DATE], LVN A said she admitted R#432 on [DATE]. LVN A said she had three days of orientation and the orientation did not include the admission process. LVN A said it was only the second admission she had done, and she asked LVN AS and RN/ADON AK to review the admission for R#432 because she wanted to be sure it was done correctly. LVN A said the next day she asked RN/ADON AK if she had completed R#432's admission correctly, and RN/ADON AK responded that she had not reviewed it but from what she knew it was done okay and she would look at it. LVN A said she did a head to toe assessment of R#432, looked at his medications from home and compared them to what the physician ordered. LVN A said the medications brought in by R#432's FM were in a little box; she said insulin was in the little box and was written on the startup orders. LVN A said the medications were already written out by LVN AS on R#432's start up orders when she proceeded with his admission, and R#432 had already arrived at the facility. LVN A said she reviewed the medications with the Nurse Practitioner who oversaw R#432's care at the facility, and she crossed out four medications and wrote error because they were no longer being ordered. In the interview on [DATE] at 4:47 p.m., LVN A said she was a relief worker and did not know the facility procedure of transcribing insulin and finger stick orders to the Diabetic MAR and putting it in the diabetic book. LVN A said she did not notice that there was no order for finger sticks for R#432 but she knew as a nurse that they should have been done. In an interview at 5:08 p.m. on [DATE], LVN R said she worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she remembered R#432 and said, He's diabetic. I checked his sugar when he was here before. He was here for respite. I saw insulin in the med cart. There was no paper for him in the diabetic book, so I thought, Okay, I guess we don't check his sugar. Why did they bring his insulin? LVN R said there were things marked out on the MAR and she did not see any time on the startup orders for insulin to be given. LVN R said, A lot of us missed it. Where's the sheet? All diabetic stuff goes on one sheet. LVN R said she told LVN AS, who worked 7:00 a.m. to 3:00 p.m., that she (LVN R) was wondering why they were not checking his sugar. LVN R said LVN AS said she wondered the same thing. Surveyor asked LVN R if she called R#432's physician to clarify whether insulin should be given to him, and she replied she did not call the physician because he could not practice any longer (surveyor was later advised that LVN R was mistaken). Surveyor asked LVN R if she notified her supervisor that there were concerns regarding R#432's insulin administration, and she replied that she answered to RN/ADON AK and she did not inform RN/ADON AK. LVN R said she overlooked doing that. LVN R said she should have notified someone. LVN R said they also missed administering R#432's Vitamins with minerals. When asked what the possible consequences were of not giving insulin to a diabetic when it was ordered, LVN R responded that the resident could go into a coma, go to the hospital or die from it. In an interview at 5:22 p.m. on [DATE], LVN CB said he worked at the facility since the end of (MONTH) (YEAR). LVN CB said R#432's orders were never transcribed to his MAR. LVN CB said R#432's startup orders were confusing to pass medications, with marks through some of the medications and other things changed. LVN CB said the insulin and minerals were at the bottom of the start up orders. He said they should have put the hours for the insulin to be given in the column next to the medication. LVN CB said insulin should have been given at 7:00 in the morning and the minerals should have been given daily. LVN CB said no doses of insulin were given and normally there should be an insulin flow sheet, but R#432 did not have anything in the diabetic flow book. LVN CB said R#432 did not have insulin in the med cart. The insulin was expired, he said, and was usually in the top middle drawer in the cart, but instead it was put in the refrigerator. LVN CB said the third shift stocked the med carts. LVN CB said RN/ADON AK said R#42's insulin was in the refrigerator. LVN CB said the insulin was not in the cart as he would have noticed it. LVN CB said he did not know R#432 was diabetic. LVN CB said the diabetic book was part of his orientation and all halls had them. In an interview at 5:45 p.m. on [DATE], LVN CR said she worked at the facility since (MONTH) 5, (YEAR). LVN CR said she was oriented on the use of the diabetic book. LVN CR said she assisted R#432 with eating lunch on [DATE], just before his FM picked him up from the facility. LVN CR said R#432 tolerated the meal well; when she moved him back in his wheelchair because he was sitting forward, LVN CR made a sighing sound. LVN CR said R#432 ate his food, drank juice, water and milk, and tried to grab liquids. LVN CR said liquids fell out of R#432's mouth as he drank. LVN CR said R#432 drank thickened liquids but she did not remember the texture of his food; he ate more than 80% of his meal, she said. LVN CR said she had no awareness R#432 was on insulin and she never administered medications to him. In an interview at 7:15 p.m. on [DATE], LVN A said she kept notes of everything she did during the day at work. She said she remembered that she did not find any insulin in R#432's box of medications that his FM brought from home. LVN A said she remembered that insulin was written on the MAR and she verified these orders with R#432's physician. LVN A said other shifts would have written on the MAR and would have seen it. In an interview at 7:23 p.m. on [DATE], RN/ADON AK said she remembered R#432 from a previous admission. RN/ADON AK said after she found out R#432 never received insulin, she noted that the insulin was written near the bottom of the start up orders and was supposed to be transcribed to the diabetic MAR, but it never made it on there. RN/ADON AK said LVN A checked in R#432's medications and she was the admitting nurse. RN/ADON AK said she was notified by LVN AS after she discharged R#432 that she found a vial of insulin and it was expired and it was from (MONTH) (YEAR); that was when everything came to light at the end of the day on [DATE]. Upon discharge on [DATE], RN/ADON AK said she stumbled upon an expired insulin vial in the refrigerator of the med room and she gave it back to FM. RN/ADON AK said she did not know how the insulin ended up in the refrigerator. RN/ADON AK said when a new resident was admitted , she checked the MARS for discrepancies. When asked if she reviewed R#432's MARS for discrepancies, RN/ADON AK said she skimmed over it but did not check the MAR and see that it was transcribed to the diabetic MAR. RN/ADON AK said it looked like a standard admission. RN/ADON AK said she saw that R#432 had insulin listed at the bottom of the start up orders. RN/ADON AK said LVN A had over three days of orientation on the floor, including shadowing another nurse. RN/ADON AK said LVN A had knowledge of the diabetic book, but she got overwhelmed and she forgot a step. RN/ADON AK said no one said they knew who put the insulin in the refrigerator. RN/ADON AK said it was not that unusual that orders were received for giving insulin without doing finger sticks as some physicians did not order accuchecks of blood sugar. RN/ADON AK said she would have expected her 7:00 a.m. to 3:00 p.m. nurses or her night shift to catch that the insulin was not transcribed to the diabetic MAR, and she said she expected more from herself. In an interview at 7:48 p.m. on [DATE], LVN A said she verified R#432's orders with a Nurse Practitioner (NP). Regarding the insulin, R#432 was supposed to be given 15 units in the morning and seven units in the evening. LVN A said she would have written in the nurse's notes if she had verified whether the NP wanted finger sticks to be done. LVN A said there was no Policies and Procedures book to look through to see if she did the admission correctly. LVN A said she could not remember if she administered any insulin to R#432. LVN A said she worked for the corporation that owned the facility ten to [AGE] years ago, and did not remember a procedure for a diabetic book. In an interview at 8:11 p.m. on [DATE], FM said R#432's blood sugar was at 150 but he was still dehydrated and in ICU at the hospital. FM said she was sure she gave the facility a whole new bottle of insulin when she took R#432 to the facility on [DATE], but she did remember removing the cap. FM said she would check the expiration date of the insulin. In an interview at 9:00 p.m. on [DATE], FM said the insulin she took to the facility on [DATE] was filled on [DATE] and had an expiration date of ,[DATE]. The insulin also said to discard the bottle after [DATE]. FM said she gave the medications to LVN AS (calling her by her first name and describing her) when she took R#432 to the facility on [DATE]. FM said when she picked up R#432 on [DATE], she noticed that on the outside of the box of insulin was written in black marker, [DATE]. FM said currently R#432's blood sugar was down to 115 and his labs were looking good, and the hospital was going to see if he would eat a little bit. In an interview at 9:58 a.m. on [DATE], LVN AS said she worked the 7:00 a.m. to 3:00 p.m. shift. LVN AS said she received R#432 alert on the day he came into the facility. LVN AS said she wrote the headers and footers of the admission packets and wrote down his medications but did not write down the times he took them. LVN AS said R#432 got to the facility at 2:45 p.m., and because she got off work at 3:00 p.m., she did not do the admission. LVN AS said she gave the incoming nurse, LVN A, report, and R#432 and FM went straight into the Social Worker's office. LVN AS said on the morning that R#432 was discharged , [DATE], LVN R gave her report and told her R#432's insulin was expired and did not need to be on the cart. The date that it was expired was written in black on the side of the insulin box; she looked at the box and it was opened in (MONTH) and did not have an expiration date. LVN AS said she knew it was only good for 28 days. She put it in the refrigerator around 7:00 a.m. on [DATE]. When R#432 left, she put all of R#432's medications in a bag and gave them to his FM. In the interview at 9:58 a.m. on [DATE], LVN AS said she passed medications to R#432 on [DATE], [DATE], [DATE], [DATE] and [DATE]. She said she passed medications to R#432 when he was at the facility before this respite stay, and she now remembered he took insulin before. LVN AS said she probably did see that R#432 had insulin written on the start up orders, and the list of medications came from a fax the facility received from the Veterans Administration with R#432's [DIAGNOSES REDACTED]. LVN AS said she remembered R#432 was supposed to be given insulin around 9:00 p.m. LVN AS said LVN A was new at the facility. LVN AS said if it was her admission, she would have rewritten the start up orders and put an asterisk on them and would have put the insulin on the insulin sheet. The start up orders would have been faxed to the pharmacy. LVN AS said she did not tell LVN A to transcribe to the insulin record. It was automatic, LVN AS said, for RN/ADON AK to review and tell her what need to be corrected on admissions. LVN AS said a resident could die if he missed his insulin for a week. In an interview at 10:30 a.m. on [DATE], the DON said she was in the process of ensuring everyone who handled admissions knew the policies and procedures for them. The DON said she did not understand who put the black marker with the date [DATE] on R#432's insulin. In an interview on [DATE] at 11:00 a.m., LVN R said she got report on [DATE] from LVN A. LVN R worked the 11:00 p.m. to 7:00 a.m. shift. LVN R said she said she knew she needed to check R#432's blood sugar and said there should have been orders for accuchecks, saying, Yes, absolutely, no doubt about it. In an interview on [DATE] at 5:26 p.m., LVN A said that she looked at some notes that she kept at home regarding medications that she gave during her shifts, and she found that she had given seven units of insulin to R#432 once or twice when he was at the facility. She said she also remembered checking his blood sugar once or twice before giving him his insulin. She said she found the insulin in the top drawer of the medication cart. After that, she said

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for three (R #432, R #17, and R #117) of eight residents reviewed for pressure ulcers. 1.) Resident #: 432 -The facility failed to assess and document a detailed description of R #432's pressure ulcers upon admission other than he was admitted with a Left Heel stage 3 and a Right Heel Stage 2. -LVN BL failed to consult with R #432's physician when she saw a change in R #432's right heel pressure ulcer, indicating a deterioration. -The facility did not provide R #432 with a second daily treatment on his right heel on 07/10/18 and 07/11/18 as prescribed by the physician. -R #432's Baseline Care Plan did not include specific preventative measures/interventions R #432 should have been provided with for off-loading purposes. 2) Resident #17: -The facility did not ensure staff applied moisture barrier cream on R #17 after each incontinent care episode, whom was identified as at risk for pressure ulcer development. -The facility failed to monitor and ensure R #17's low air loss mattress (identified by the facility as being used as a preventative measure to prevent pressure ulcer development) was set at the accurate setting. R #17's mattress was set at 400 pounds however, R #17 weighed 94 pounds. -CNAs Z and AX did not identify or report that R #17 had an open area on her sacrum, after providing her incontinent care. After the surveyor's inquiry, the facility identified R #17's open area as a Stage 2 pressure ulcer. 3) R #117: -The facility failed to ensure that R #117 was repositioned every two hours as indicated in her care plan. R #117 layed in the same position for over three hours. -CNAs Z and AX did not identify or report that R #117 had an open area on her right hip and purple discoloration to her left lateral great toe, after providing her incontinent care and repositioning. R #117 developed a facility acquired Stage 2 pressure ulcer to her right hip and a Deep Tissue Injury to her left lateral great toe and the facility was not aware until the surveyor's inquiry. These failures could place 11 residents with pressure ulcers and 124 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers. The findings included: 1.) R #432: Review of the Face Sheet dated 07/10/18 revealed R #432 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R #432 was [AGE] years old and entered the facility under a Veteran's Administration respite care stay. R #432 was discharged home with his responsible party (RP). on 07/16/18. Immediately after discharge from the facility, R #432's Responsible Party took R #432 to the Emergency Department where he was found to have a blood sugar level of 952 and was admitted to the Intensive Care Unit. Review of R #432's Minimum Data Set ((MDS) dated [DATE], from a recent respite care stay, revealed he had cognitive loss/dementia and pressure ulcers. Though surveyor requested copies of R #432's MDS, most pages of the MDS were missing. R #432's Start Up Orders dated 07/09/18 revealed no wound care orders. Review of Admission Data Summary/Progress Note dated 07/09/18 revealed R #432 was admitted for a respite stay. His ADL (Activities of Daily Living) function prior to admission was that he required the assistance of one for mobility and transfer; required some assistance/cueing with eating; was incontinent of bowel and bladder and had some communication difficulty with finding words or finishing thoughts. R #432 had an unstable gait, weakness, was confused, disoriented or hallucinating. He had short-term and long-term memory problems, could usually understand others and make himself understood. R #432 was not in pain. R #432 was not at risk for wandering, but was at risk for weight loss due to chewing/swallowing problems. R #432 had moderately to severely impaired cognition and weakness in his upper extremities. R #432 had a Stage 3 pressure ulcer on his left heel measuring 0.5 X 0.5 X 0.2 centimeters (cm); and on his right heel he had a red area, Stage 2 pressure ulcer measuring 1.8 X 1.5 cm. -There was no other documentation of the detailed description of the ulcers, other than measurements. There was no pressure ulcers documented. The Admission Data Summary dated 07/09/18 indicated R#432 was Diabetic and had [MEDICAL CONDITIONS]. He had some foot problems, open [MEDICAL CONDITION] on his foot and required application of dressings. -There were no detailed descriptions of the wounds on his feet. R #432's Physician Telephone Orders dated 07/09/18 documented Apply Barrier Cream to buttocks q (every) shift and prn (as needed) .Cleanse left heel Stage 3 (Full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue are often present. Slough and/or eschar may be visible) with NS (normal saline), pat dry, apply calcium alginate, cover with 4 X 4 and wrap with kerlix QD (every day) Apply skin prep to right heel Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) twice a day. Review of R #432's Admission/Baseline Care Plan dated 07/09/18, completed by Licensed Vocational Nurse (LVN) A, revealed he had some current pressure injury, and should be turned every two hours and prn, follow facility skin care guidelines, and preventative measures. -The Care Plan did not explain or list the preventative measures to be used for R #432. Review of R #432's Immediate Needs Care Plan/Risk for Skin Breakdown dated 07/09/18, signed by Registered Nurse (RN) G, who was a wound care nurse, revealed interventions included completing the skin risk assessment weekly to include heels; following ADL care directives; using pillows for support to prevent skin to skin contact; providing and encouraging fluids at each meal and in between; floating heels with pillows; and prevalon boots. R #432's Skin Assessment Flow Sheet - Pressure Injury dated 07/09/18 documented by Registered Nurse (RN) G revealed: Left Heel: Stage 3: 0.5 X 0.5 X 0.2 cm, D (drainage). Right Heel: Stage 2: 1.8 X 1.5 X 0.0 cm, D. -There was no other detailed description of the ulcers documented, making it difficult to know the wounds appearance, amount, and type of drainage. R #432's Clinical Conditions Predicting High Risk for Pressure Injury dated 07/09/18 documented a score of 14-Moderate Risk. R #432's Admission Weekly Skin assessment dated [DATE] revealed R #432's left and right heel were circled on the body diagram indicating skin impairment to those areas. Review of Progress Note dated 07/10/18, completed by R #432's Nurse Practitioner (NP), revealed he had a DTI (Deep Tissue Injury- Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister) on his right heel and a Stage 3 on his left heel. R #432's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed Cleanse left heel Stage 3 ulcer with NS, pat dry with 4X4 gauze, apply calcium alginate. Cover with 4X4 and wrap with kerlix daily - Start 07/09/18. The TAR documented that this treatment was done daily beginning on 07/09/18 and ending on 07/16/18. Stage 2 ulcer: apply skin prep to right heel BID (twice daily) 7-3 and 3-11 shift, starting 07/09/18. The 7:00 a.m. to 3:00 p.m. documented that the treatment was provided daily from 07/09/18 to 07/16/18; the 3:00 p.m. to 11:00 p.m. shift documented the treatment was done 07/12/18 through 07/16/18. R #432's Weekly Skin assessment dated [DATE] revealed R #432's left and right heel were circled on the body diagram indicating skin impairment to those areas. Review of R #432's progress/Nurse's Notes dated 07/09/18 - 07/16/18 revealed no detailed description of R #432's pressure ulcers or head to toe skin integrity. Interview with the Director of Nurses (DON) on 07/17/18 at 11:30 a.m. revealed she said LVN CR, the wound care nurse, fed R #432 lunch on 07/16/18. The DON said R #432 was discharged and picked up by his granddaughter at 2:00 p.m., 30 minutes later he was taken to the hospital with his blood sugar level at 962. The DON said R #432's granddaughter called her and informed her of R #432's status then said she reviewed his chart and confirmed staff did not provide R #432 with any insulin prescribed his entire stay at the facility. The DON said there was no documentary evidence that R #432 was admitted with or developed any pressure ulcers to his buttocks while in the facility. The DON verified R #432 did enter the facility with a left heel stage 3 and a right heel stage 2 pressure ulcer. The DON confirmed R #432 required staff assistance for positioning and incontinent care at least every two hours. After reviewing R #432's (MONTH) (YEAR) TAR, she said If they did not initial it then the treatment was not done. It looks like he may have not received at least two treatments on the second shift. The DON verified that R #432's care plan did not include specific preventative devices/measures to be used and confirmed the care plan should have had specific interventions addressed in the care plan to ensure that all staff were consistent with the care R #432 required. Observation of R #432 on 07/17/18 at 4:20 p.m. at a local hospital revealed he was lying in bed, on an air mattress with his eyes closed. R #432 did not awaken to knock or verbal stimuli. R #432 had intravenous (IV) fluids with potassium, and IV antibiotics infusing via a central line. R #432's arms, body, and legs were completely covered. Hospital Registered Nurse (RN) Z stated she had given R #432 IV pain medication prior to the surveyor's visit because R #432 had facial grimaces and confirmed pain to his buttocks. RN Z said R #432 had intermittent confusion on a daily basis. Review of R #432's hospital Complex Wound assessment dated [DATE] documented: -Left buttock pressure ulcer site measures 2.1 X 2.0 X 0.1 centimeters, wound bed with 100% red tissue and darkened/intact periwound. -Left gluteal fold pressure ulcer measures 2.1 X 2.0 X 0.1 centimeters, wound bed with 100% red tissue and periwound within normal limits. -Right buttock pressure ulcer measures 2.5 X 2.7 X 0.1 centimeters, with 100% red tissue in wound bed and periwound macerated. Applied triad to entire area. Recommend BID (twice daily)/ prn- soiled, off load every two hours, and place on specialty mattress. -Plantar right foot pressure ulcer with site black dry eschar surrounded by redness that measures 0.6 X 0.3 X eschar .Continue posey boots. -Left lateral heel pressure ulcer with red blanchable redness, previous healed ulcer .continue offload. -Right Heel pressure ulcer - existing dressing removed with scant yellow drainage and no odor. Site measures 1.0 X 1.5 X unknown depth, wound bed with 95% tan necrotic tissue and 5% pink tissue. Immediate periwound macerated with partial thickness at 9 o'clock, followed by pink tissue. Interview with RN G on 07/17/18 at 4:30 PM revealed she confirmed she assisted the admitting nurse to assess R #432's skin on admission on 07/09/18. RN G said she did not document a description of R #432's wound anywhere else other than the Skin Assessment Flow Sheet dated 07/09/18. I should have described the wound better on his Skin Assessment Flow Sheet-Pressure Injury Form, I do not know why I didn't do it. Well it is important to document a detailed description of the wounds to be able to track the wound progress. RN G said R #432 did not have any skin impairment to his buttocks at the time of admission. Interview with Licensed Vocational Nurse (LVN) CR on 07/17/18 at 05:51 PM revealed she confirmed she conducted a head to toe assessment of R #432 on 07/14/18. LVN CR said R #432 did not have any skin impairment or pressure ulcers to his buttocks on admission or on 07/14/18. LVN CR said she did not see R #432's buttocks anytime after 07/14/18. LVN CR said she had not been made aware that he had any open wounds on his buttocks. After showing LVN CR hospital pictures of R #432's pressure ulcers, LVN CR said R #432's right heel was not open on the 14th. The 14th was the last day I saw the wound on his right heel. It looked like a blood blister; the skin was fully intact, was not open, no drainage at all. After LVN CR reviewed R #432's hospital picture of his left heel she stated It was nothing like that. I can't recall how it looked. The left heel was the worst one at that time, it was worse than the right heel. After LVN CR reviewed R #432's Admission Skin Assessment Flow Sheet - Pressure Injury dated 07/09/18 (documented by RN G), LVN CR said she could not make out a clear picture of the appearance of R #432's pressure ulcers because There is not enough description documented. There should be more documentation of the color, including percentages of the tissue color in the wound bed. There should also have been more detail of the type, amount, and odor of drainage. Comparing his hospital pictures to his Admission Skin Assessment, his right heel worsened and his left heel improved. I guess he acquired the three ulcers on his buttocks while he was here if he arrived at the hospital with them. If he developed them here, we should have known because he was supposed to be changed by staff every two hours and should have been provided a bath by our staff three times a week. LVN CR confirmed she did not document any description of R #432's pressure ulcers any where else in his clinical record. Interview on 07/17/18 at 06:29 PM with LVN BL revealed she stated she was familiar with R #432 because had been admitted a couple of times for respite care. LVN BL said R #432 Had the same wounds on his heels since he has been coming here for respite. LVN BL said she only saw R #432 once on Sunday on 7/15/18. LVN BL said she recalled R #432 had a left heel stage 3 and right heel stage 2. LVN BL said she made herself a note to check with RN G because I thought the wounds were documented the opposite-maybe the right heel stage 3 and left heel stage 2. I thought the left heel heel should have been a DTI and the right heel an unstageable; The left heel had a DTI, with a maroon discoloration, not open, no drainage. The right heel had a dark brown scab with a small aspect of the wound open with red bound bed. The scab was eschar. The periwound had some white maceration. LVN BL confirmed she did not document her finding/changes in the wounds or notify the physician of the wound changes because she was going to consult with LVN CR on the next day. LVN BL said since she was assessing R #432 as he was laying in bed, she thought maybe I'm wrong and I hadn't seen him since he had been here. I thought maybe I got my right and left wrong and remember saying to myself, I'll check it tomorrow. LVN BL said she on 07/16/18 she was made aware that R #432 was going home and said she did not report any of R #432's wound changes and did not re-assess the wounds before he discharged . LVN BL reviewed R #432's Skin Assessment Flow Sheet dated 07/09/18 and said This is not a detailed description of the wound. It should document surrounding tissue, color, how much drainage. LVN BL said a consequence of not accurately documenting the detailed description of the wounds could lead to incorrect treatment of [REDACTED]. LVN BL explained that the facility admission/pressure ulcer procedure was that the admitting nurse started with the trifold admission assessment. If the resident had any pressure ulcers, the admission nurse informed the treatment nurse and the treatment nurse performed her own assessment. If the admission nurse found any area open, they consult with the physician and to documented the telephone orders for treatment of [REDACTED]. The nurse would suggest the wound protocol but would have to get permission from the physician to use the wound protocol for that specific resident. LVN BL said We need physician approval to implement the protocol. Every morning the treatment nurses checked all new orders placed in their box by the nurse and we also check all new admissions. LVN BL reviewed R #432's hospital wound pictures and said On 07/15/18, his right heel didn't look so macerated- it was dry and crusted with no drainage, it was yellow too. Compared to when I saw it on 07/15/18, the right heel looks worse in the picture. The left heel looked pink and intact. LVN BL said she did not assess any other body part of R #432 on 07/15/18, except his heels. LVN BL said her assessment of R #432's right heel had worsened from it's initial Stage 2 because yellow scab would indicate eschar, looked like an unstageable vs. a stage 2; yellow tissue does not meet the definition of a Stage 2. Interview with the DON on 07/18/18 at 10:30 a.m. revealed she was made aware and shown R #432's hospital pictures of his pressure ulcers. The DON reviewed R #432's admission Skin Assessment Flow Sheet dated 07/09/18 and said It looks like his right heel deteriorated but there is no documentation of it. There is no documentation of any breakdown on his buttocks either. The nurse should have documented the description of the wound like color, percentage of color in the wound bed, surrounding skin and margin status, any odor, what type and amount of drainage. Reading the documentation on this assessment I can't tell what the wound looked like. The DON was asked about the facility's wound protocol and said The protocol are one of the wound care specialist's standing orders, the nurses still need to call the physician and describe the wound to the physician and they could suggest the protocol but it was up to the physician what treatment he prefers for the resident. If any nurse see's a change in the wound status, they should be calling the physician to report that and see if he wanted to continue the same treatment because if the wound is getting worse, it may need a more aggressive treatment to prevent worsening or if the wound is improving then the current treatment may need to be changed to prevent harm to the healing wound bed. The DON stated R #432 should have been assessed head to toe prior to leaving the facility so We have documentation of his status upon his discharge, I do not see that was done either. I just started working four days ago but I immediately picked up on systems failures by day two. The nurses stopped following policy and procedures and did not document accurately and efficiently. The DON agreed that the nursing staff should have identified R #432's wound status since he required incontinent are every two hours and had a full body assessment had been done prior to him leaving the facility. The DON confirmed the facility did not have any shower skin sheets for R #432, which she said The CNAs are responsible to fill out a sheet when they see any skin impairment during the shower. 2.) R #17 R #17's Face Sheet dated 07/21/18 documented a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #17 was receiving hospice services. R #17's Care Plan dated 06/06/18 documented I am at risk of impaired skin integrity related to immobility, incontinence, nutritional deficits, and decline in medical condition .The staff will examine my skin daily for signs of redness, discoloration. They will assess areas prone to breakdown (over boney prominence's); I will need to have pericare after each incontinent episode; Apply moisture barrier after each incontinent episode; I need to be turned and repositioned every two hours and prn. Please avoid shearing my skin any using a draw sheet with two staff members positioning me; I need a pressure reducing mattress on bed . R #17's Annual Minimum (MDS) data set [DATE] revealed R #17: -had short and long-term memory problem and had moderately impaired cognitive skills for daily decision making; -was totally dependent with one or two person physical assist for bed mobility, transfers, dressing, eating, and personal hygiene; -was always incontinent of bowel and bladder; and -was at risk of developing pressure ulcers but did not have any pressure ulcers at the time of this assessment. R #17s Clinical Conditions Predicting High Risk for Pressure Sore Development dated 07/11/18 revealed a score of 12- High Risk. Observation of R #17 on 07/17/18 at 11:02 AM revealed R #17 was lying in bed, on her back, lying on a low air loss mattress (LALM) with the mattress pump set at 400 pounds normal, alternating pressure. On pump was a sticker that read Between 80-100. R #17 appeared to be frail and weighing less than 100 pounds. Observation of R #17 on 07/18/18 03:27 PM revealed she had her eyes closed, not awakening to verbal stimuli, lying on her back on a LALM with the mattress pump set on 400 pounds. On 07/19/18 at 03:47 PM Certified Nurse Aides (CNAs) Z and AX were preparing R #17 for incontinent care. CNA Z stood on R #17's left side of and CNA AX stood on R #17's the right side. This surveyor stood behind CNA Z as they began providing incontinent care for R #17. R #17 was lying on her right side with a pillow between her legs. As CNA Z wiped R #17's buttocks, this surveyor noticed R #17 had an open area with pink wound bed on her sacrum, over her protruding bony prominence with no dressing on. CNA Z wiped over the area twice with a disposable wipe and did not say anything. CNA AX asked CNA Z if she was going to put on cream. CNA Z replied There isn't any, I will put some on the next time I change her. R #17 was left lying on her LALM with the pump set at 400 pounds normal, alternating pressure. After positioning R #17 for comfort, both CNAs stated R #17 could not reposition herself therefore, staff had to reposition her every two hours. CNA AX said they used protective barrier cream on the residents who were incontinent to prevent skin breakdown. Interview with LVN BL on 07/19/18 at 4:00 p.m. revealed she stated R #17 did not have any pressure ulcers. LVN BL was asked to inspect the setting of the air mattress pump and verified the LALM pump setting was set at the wrong setting. The pump should be set at 100 pounds because she weighs 97 pounds. That is why I put the sticker on the pump indicating 80 - 100 pounds. All the licensed nurses, including myself, who care for her are responsible for ensuring the pump is set correctly every time they come in the room. I checked it daily, I do not know why it is on 400 pounds. It must have got stuck on that setting. LVN BL retrieved CNA Z to assist her to turn R #17. LVN BL confirmed R #17 had a New Stage 2 pressure ulcer. LVN BL described the wound as open with pink wound bed, peri-wound without redness. LVN BL measured the wound as 1.0 X 0.4 X 0.1 centimeters. LVN BL cleaned the wound with normal saline, pat dried, applied hydrogel (topical antimicrobial ointment) over the wound bed, applied a foam dressing, and secured the wound with bordered gauze. LVN BL said a firm air mattress could be detrimental to her skin and cause pressure ulcers. I used hydrogel according to my Pressure Ulcer Quick Reference Guidelines/protocol. We use that as a protocol to provide the treatment without calling the physician. I will call the physician though as soon as we are done, he always agrees with what I use as treatment for [REDACTED].#432 had any new impaired skin conditions. LVN BL said the CNAs should be applying moisture barrier cream on R #432 after each brief change to protect her skin and prevent skin impairment. Interview with CNAs Z and AX on 07/19/18 at 04:56 PM revealed she stated she did not see R #432's open wound while providing her with incontinent care. CNA Z did not answer the surveyor when asked how the surveyor was able to see the wound while standing behind her as she was wiping R #432's buttocks. Review of R #17's Wight Record dated 07/2018 revealed R #432's weight on 07/06/18 was 94 pounds. R #17's Skin Assessment Flow Sheet - Pressure Injury dated 07/19/18 documented Coccyx Stage 2: 1.0 X 0.5 X 0.1 cm, pink wound bed. R #17's Hospice Nursing Assistant Daily Body Observation Form dated 07/20/18 documented No skin problem. Review of R #17's undated Med-Aire Alternating Pressure Mattress Replacement System with Low Air Loss Operator's Manual documented Operation: Pressure Set Up: Note! It is recommended that the pressure-adjust knob turned to Firm or press Auto Firm on the panel when the mattress is first initiated. Users can then adjust the air mattress to a desired firmness according to the patient's weight and comfort . 3.) R #117 R #117's Face Sheet dated 07/13/18 documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #117s Clinical Conditions Predicting High Risk for Pressure Sore Development dated 06/01/18 revealed a score of 14- Moderate Risk. R #117's Weekly Skin assessment dated [DATE] documented no areas of skin impairment. R #117's Weekly Skin assessment dated [DATE] documented no areas of skin impairment. R #117's Quarterly Minimum (MDS) data set [DATE] revealed R #117: -had short and long-term memory problem and had severely impaired cognitive skills for daily decision making; -was totally dependent with one or two person physical assist for bed mobility, transfers, dressing, eating, and personal hygiene; -was always incontinent of bowel and bladder; and -was at risk of developing pressure ulcers but did not have any pressure ulcers at the time of this assessment. R #117's Care Plan dated 06/24/18 documented At risk for impaired skin integrity related to incontinence of bowel and bladder elimination and immobility .Staff assist for turning and repositioning every 2 hours and PRN; Staff will monitor skin integrity daily with ADL care and report any noted concerns to charge nurse; mattress overlay; Float heels when in bed/offload . R #117's Weekly Skin assessment dated [DATE] documented no areas of skin impairment. R #117's Weekly Skin assessment dated [DATE], 07/09/18, and 07/16/18 documented no areas of skin impairment. Observation of R #117 on 07/16/18 at 1:00 p.m. revealed she was lying on her left side, in a fetal position, with one pillow tucked between her lower legs. R #432 did not have any devices on her feet nor were her feet off-loaded. R #117's LALM was set on 100 pounds. Observation of R #117 on 07/16/18 at 02:10 PM revealed she was laying on her left side, in a fetal position, with a pillow between her feet. R #117 had her eyes closed and did not awaken to verbal stimuli. CNA Z entered the room and said She is bedbound, dependent on staff for positioning and does not talk. No off-loading devices were used to off-load her feet off the bed. Observation of R #117 on 07/16/18 at 4:40 p.m revealed R #117 continued to lay on her left side in a fetal position with a pillow between her lower legs/feet. No off-loading devices were used to off-load her feet off the bed. On 07/19/18 at 04:00 PM, CNA Z and AX began providing R #117 with incontinent care. R #117 was laying on her left side in bed. As the surveyor stood beside CNA AX as she cleaned R #432, the surveyor observed R #117 had purple discoloration to her left lateral great toe. Her right hip hand a healed scar however, within the center of the scar was an open area with a pink wound bed. At 4:13 p.m., the CNAs positioned R #117 on her left side again, placing a pillow between her legs however, R #432's right foot rested on her left lateral foot applying pressure to the left lateral great toe discolored area. No offloading devices were used for R #117's feet. On 07/19/18 at 04:54 PM LVN BL assessed R #117's right hip and stated She had an ulcer to that hip before but it had been healed. Oh yes, it has re-opened. No I had not been made aware of her having any skin breakdown. So because the wound has re-opened, we will stage it as what it was staged at in the past since it is on the same site. LVN BL assessed R #117's feet and confirmed R #117 Has a new DTI (Deep Tissue Injury) on her left lateral great toe. LVN BL measured R #117's left lateral great toe as 1.5 X 2.5 centimeters, It has purple discoloration with non-blanchable redness surrounding the purple discoloration. LVN BL cleaned the left lateral great toe with normal saline then applied skin prep to the area. LVN BL said She has had skin breakdown on her toes before because she is so contracted. At 5:21 p.m., LVN BL measured R #117's right hip as 0.5 X 0.6 centimeters. LVN BL said It is open with pink wound bed with no redness to peri-wound area but was a site of a previous pressure ulcer. I would stage it as a Stage 2 but I am going to look up to see what her previous wound was staged at. It has been several months since the right hip had been healed. The CNAs should have noticed the wounds because these two residents are incontinent, are on an air mattress, and get repositioned and changed every two hours. LVN BL confirmed R #117 weighed 98 pounds. LVN BL stated R #117 should have had a pillow between her feet to avoid the bony prominence's to touch, to prevent pressure to those areas. LVN B said it was possible that not repositioning at least every two hours and allowing prominence's to touch could have caused R #117's pressure ulcer formation. Interview with CNA AX on 07/19/18 at 5:25 p.m. revealed she stated I did not notice those wounds. I would have told her nurse if I had seen them. R #117's Skim Assessment Flow Sheet- Pressure Injury dated 07/19/18 documented Right Hip: Stage 2 - 0.5 X 0.6 X 0.1 cm, non-draining wound red bed. Left Great Toe: DTI - 1.5 X 2.5 X 0.0 cm, purple coloring to area. Interview with the DON on 07/19/18 at 5:40 PM revealed she was made aware of the findings of R #17 and R #117. The DON said both of the residents could not reposition or off-load themselves therefore the staff needed to provide that care for them. The DON said the CNAs should have been more aware of the area as they are cleaning them and should have immediately reported it to the nurse and/or treatment nurse. The DON again confirmed The nurses cannot implement a wound protocol until first discussing it with the physician and the physician provided that nurse with an order for [REDACTED]. The facility's Skin- Treatment Guidelines for Pressure Injuries documented It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury. NOTE: These are treatment suggestions, and do not supersede a physician's orders [REDACTED]. -Each pressure injury must have a separate order. -Each pressure injury site must be identified by location. -Product to be used must be named. -If special tape is required. state in orders. -Frequency of the dressing change must be indicated. -D

Based on observation, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one Resident (R#2) out of nine residents reviewed for accident hazards. Housekeeping staff failed to clean up water on the floor in R#2's room as a result, R#2 fell and was transported to the emergency room and had sustained a laceration to the forehead requiring sutures. An Immediate Jeopardy (IJ) was determined to have existed from 09/26/16 to 09/29/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began. The Non-Compliance was removed on 09/29/16 when all staff was in-serviced on safety in the workplace and potential hazards. The houskeeping staff involved also received individual retraining and were disciplined. The failure to follow-up on potential hazards could affect 24 residents who required assistance with ambulation or other assitive devices in the facility. The findings were: R#2's Face Sheet dated 09/27/16 indicated R#2 was admitted to the facility on [DATE]. The Face Sheet indicated the latest return to the facility was 09/14/15. The Face Sheet indicated the resident was [AGE] years old. R#2's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#2 had clear speech; was usually understood and had the ability to usually understand others. R#2 was able to report the correct year, month and day. The MDS indicated R#2 was independent with no setup or physical help from staff for bed mobility, transfer, walk (with a walker) and toilet use. She did require supervision and setup help for dressing and personal hygiene. She also required setup help for eating. Active [DIAGNOSES REDACTED]. R#2's Care Plan, Start date: 08/04/15 indicated R#2 had the potential for falls, injuries due to the side effects of her depression medication. The Care Plan indicated that R#2 fell in her room due to water on the floor from her refrigerator and R#2 had sustained a laceration to the forehead. The resident was sent to the emergency room (ER) and had received sutures to the forehead. Physician Assistant (PA) C's Progress Note dated 09/27/16 indicated the resident fell in her room. The PA stated R#2 reported there was water on the floor and she had slipped. The note indicated the resident had gone to the ER the day before (09/26/16) for evaluation of a laceration to the forehead. R#2 had returned with several staples to her forehead. The note continued, She has ecchymosis (discoloration of the skin resulting from bleeding underneath) to her both eye sockets. Raccoon eyes will form over the next few days. I informed the patient her facial appearance will look worse but it will resolve in 3 weeks. The patient is stable today and as mentally as intact as when I last saw her 2 weeks ago. Provider Investigation Report dated 09/27/16 indicated the incident occurred on 09/26/16 at 11:00 a.m. in R#2's room. Incident Category was checked for Neglect. The report indicated R#2 required no special supervision; her functional ability was that she required minimal assistance; R#2 was independently ambulatory, interviewable and was not capable of making informed decisions. The report named two staff persons as alleged perpetrators (AP) which were identified by names and by interviews. The APs denied allegations according to the report. The description of the allegation was that R#2 fell in her room and she reported she had notified the housekeeper there was water on the floor and the housekeeper gave her a gown to soak up the water. The description of the injury was a fall resulting in sutures in the head. Description of the assessment was that pressure was applied to the forehead laceration and R#2 was sent to the ER and returned at approximately 3:30 p.m. the same day. The Provider response was that the Physician and Responsible Party were notified; R#2 was sent to the ER; initiated investigation; counseling/inservices done; R#2's refrigerator was removed from her room to determine if water caused the spill or if the refrigerator was leaking. The investigation summary indicated R#2 had spilled water in her refrigerator; R#2 informed housekeeper (HK) D and R#2 was given a gown to soak up the water. HK E stated R#2 told her there was water on the floor, and HK E told R#2 to tell HK D. The report added R#2 was interviewable, but did not recall telling HK E. The investigation findings were inconclusive. Provider action taken post-investigation was that both housekeepers were counseled/inserviced and resident and staff interviews were done. Hospital Discharge Summary dated 09/26/16 at 2:19 p.m. indicated R#2 was treated for [REDACTED].#28 tablets 1 tablet every 12 hours. Follow-up notes indicated that on 09/26/16 R#2 was treated at the hospital and that sutures needed to be removed in seven days and the resident should return to the ER if symptoms worsened. Written statement dated 09/26/16 at 11:15 a.m. by HK D indicated HK D was passing out clothes on the 300 hall when she heard R#2 yell for help. HK D added she saw R#2 on the floor and she notified Certified Nurse Aide (CNA) F. HK D indicated R#2 never asked her to clean up any water. Witness statement dated 09/26/16 written by CNA F indicated she heard a loud thump then hollering went to the resident's room resident was on the floor bleeding from forehead. CNA F wrote she had notified the charge nurse and another CNA brought wash cloths to help stop the bleeding. CNA F added the resident told her she was cleaning the water off the floor herself because she had told the housekeeper and the housekeeper had told her to clean it up herself, then gave the resident a gown. Written statement dated 09/27/16 by HK E indicated she was walking down the 300 hall when passing by R#2's room, R#2 told her there was water on her floor and she had directed her to HK D and HK E kept walking down the hall. HK E statement indicated that sometime after 12:00 someone had said R#2 had fallen. Written statement by the Administrator dated 09/27/16 indicated HK E stated that R#2 told her there was water on her floor and HK E told R#2 there is (HK D) you need to tell her, and (R#2) said ok. Interview/Statement of HK D dated 09/27/16 written by the Administrator indicated HK D reported she had cleaned R#2's room around 7:30 a.m., while R#2 was at dialysis, as she always did and that there was no water on the floor and had never seen water on R#2's floor. HK D stated that when R#2 returned from dialysis, R#2 had told her that R#2 had spilled water inside of her refrigerator. HK D was passing clothes and she handed R#2 a hospital gown to soak up the water in the refrigerator and that R#2 never said water was on the floor. When asked why she gave her a gown instead of a towel, HK D stated she did not see any towels in the cart. HK D then stated that around 11:00 or 11:15 a.m., she was in the hallway and heard R#2 scream and HK D ran down to R#2's room and about the same time CNA F came into R#2's room and told HK D to get out. Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and HK D provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. During an interview with R#2 on 11/08/16 at 2:35 p.m., R#2 was observed to have a scar, approximately two inches in length on her forehead. R#2 reported she had gone to dialysis and when she returned to her room, somebody had taken a glass out of her personal refrigerator and there was lots of water on her floor. R#2 stated she tried to get HK D to clean up the water, but that HK D told her to wipe it up herself. R#2 stated she remembered falling and hitting her head, but did not know what she hit her head on. R#2 reported her forehead bled like crazy and it hurt. R#2 stated the staff thought there was something wrong with her refrigerator, but that someone had spilled the water that was in her refrigerator. Observation of the refrigerator indicated there were two large mugs with secure lids with water in her refrigerator. There were also two 14 ounce(oz) empty plastic glasses with a lid on a table. R#2 stated it was one of those 14 oz plastic glass that had spilled on the floor the day she fell . During an interview on 11/09/16 at 8:47 a.m., HK D stated she had worked at the facility for [AGE] years. HK D stated she was passing clothes in the 300 hall when R#2 told her there was water spilled inside her icebox. HK D stated she gave R#2 a gown and told her to put it inside the icebox, adding, she didn't tell me to come clean the spill. HK D added that common sense told her she should have gone to check the spill herself, but because she was busy passing out clothes and because R#2 said it was inside the icebox, and not on the floor, she did not go check for herself. HK D stated R#2 took the gown and left while the HK continued passing out the clean laundry. HK D stated that right away, she heard R#2 screaming and yelling and HK D went to R#2's room. HK D stated she was shocked and went blank when she saw R#2 on the floor. HK D said she too started yelling and that was when CNA F came into the room. HK D stated she had been suspended for a day and the Administrator told her she should have gone to see when R#2 notified her of the water spill. During an interview with CNA F on 11/09/16 at 9:13 a.m., CNA F stated she had not been aware that R#2 had returned from dialysis, and she was in another room providing care. When CNA F walked out of the room, she heard a loud thump and someone screaming. CNA F stated R#2 was on the floor, bleeding and lots of blood was pouring out of her forehead. CNA F stated she hollered for the other CNA to bring her some towels to apply pressure to the laceration. CNA F stated she could see the bone on the resident's forehead. R#2 told her there was water on the floor and she had asked the HK to clean it up. R#2 told CNA F that the HK gave her a gown and said to clean it up herself. CNA F stated the floor was wet when she came into the room and the gown was on the floor, adding there was a lot of blood mixed with the water. CNA F stated R#2 told her she had left an open glass of water in the refrigerator and thought it had been spilled when her room was cleaned earlier that day. During a telephone interview on 11/09/16 at 10:00 a.m., HK E stated the day R#2 fell , HK E was on her lunch break. HK E stated she was walking down the 300 hall, on her way to lunch when R#2 told her there was water on the floor in her room. HK E stated she told R#2 that HK D was there and to tell her about the water spill. HK E added she had not gone into the room to see the water spill on the floor. HK E stated she got a write up and was inserviced, because she should have gone into the room to see about the spill. The facility's Policy and Procedure, Subject Abuse-Reportable Events revised date: 08/2016 indicated that neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was determined to have existed from 09/26/16 through 09/29/16. The IJ was removed on 09/29/16 because observation, interview and record review indicated housekeeping and nursing staff had been in-serviced on safety in the workplace and potential hazards. The two housekeeping staff were also in-serviced individually and were disciplined in writing. The facility took the following action to correct the non-compliance: Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and (HK D) provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. The facility reported on 11/10/16 there were 24 residents in the facility who requires assistance with ambulation or assistive devices.

Based on observation, record review and interview, the facility failed to implement written policies and procedures that prohibit neglect for one Resident (R#2) out of nine residents reviewed for neglect. Housekeeping staff failed to clean up water on the floor in R#2's room as a result, R#2 fell and was transported to the emergency room and had sustained a laceration to the forehead requiring sutures. An Immediate Jeopardy (IJ) was determined to have existed from 09/26/16 to 09/29/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began. The Non-Compliance was removed on 09/29/16 when all staff was in-serviced on safety in the workplace and potential hazards. The houskeeping staff involved also received individual retraining and were disciplined. The failure to follow-up on potential hazards could affect 24 residents in the facility who requires assistance with ambulation or assistive devices. The findings were: The facility's Policy and Procedure, Subject Abuse-Reportable Events revised date: 08/2016 indicated that neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#2's Face Sheet dated 09/27/16 indicated R#2 was admitted to the facility on [DATE]. The Face Sheet indicated the latest return to the facility was 09/14/15. The Face Sheet indicated the resident was [AGE] years old. R#2's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#2 had clear speech; was usually understood and had the ability to usually understand others. R#2 was able to report the correct year, month and day. The MDS indicated R#2 was independent with no setup or physical help from staff for bed mobility, transfer, walk (with a walker) and toilet use. She did require supervision and setup help for dressing and personal hygiene. She also required setup help for eating. Active [DIAGNOSES REDACTED]. R#2's Care Plan, Start date: 08/04/15 indicated R#2 had the potential for falls, injuries due to the side effects of her depression medication. The Care Plan indicated that R#2 fell in her room due to water on the floor from her refrigerator and R#2 had sustained a laceration to the forehead. The resident was sent to the emergency room (ER) and had received sutures to the forehead. Physician Assistant (PA) C's Progress Note dated 09/27/16 indicated the resident fell in her room. The PA stated R#2 reported there was water on the floor and she had slipped. The note indicated the resident had gone to the ER the day before (09/26/16) for evaluation of a laceration to the forehead. R#2 had returned with several staples to her forehead. The note continued, She has ecchymosis (discoloration of the skin resulting from bleeding underneath) to her both eye sockets. Raccoon eyes will form over the next few days. I informed the patient her facial appearance will look worse but it will resolve in 3 weeks. The patient is stable today and as mentally as intact as when I last saw her 2 weeks ago. Provider Investigation Report dated 09/27/16 indicated the incident occurred on 09/26/16 at 11:00 a.m. in R#2's room. Incident Category was checked for Neglect. The report indicated R#2 required no special supervision; her functional ability was that she required minimal assistance; R#2 was independently ambulatory, interviewable and was not capable of making informed decisions. The report named two staff persons as alleged perpetrators (AP) which were identified by names and by interviews. The APs denied allegations according to the report. The description of the allegation was that R#2 fell in her room and she reported she had notified the housekeeper there was water on the floor and the housekeeper gave her a gown to soak up the water. The description of the injury was a fall resulting in sutures in the head. Description of the assessment was that pressure was applied to the [MEDICAL CONDITION] and R#2 was sent to the ER and returned at approximately 3:30 p.m. the same day. The Provider response was that the Physician and Responsible Party were notified; R#2 was sent to the ER; initiated investigation; counseling/inservices done; R#2's refrigerator was removed from her room to determine if water caused the spill or if the refrigerator was leaking. The investigation summary indicated R#2 had spilled water in her refrigerator; R#2 informed housekeeper (HK) D and R#2 was given a gown to soak up the water. HK E stated R#2 told her there was water on the floor, and HK E told R#2 to tell HK D. The report added R#2 was interviewable, but did not recall telling HK E. The investigation findings were inconclusive. Provider action taken post-investigation was that both housekeepers were counseled/inserviced and resident and staff interviews were done. Hospital Discharge Summary dated 09/26/16 at 2:19 p.m. indicated R#2 was treated for [REDACTED].#28 tablets 1 tablet every 12 hours. Follow-up notes indicated that on 09/26/16 R#2 was treated at the hospital and that sutures needed to be removed in seven days and the resident should return to the ER if symptoms worsened. Written statement dated 09/26/16 at 11:15 a.m. by HK D indicated HK D was passing out clothes on the 300 hall when she heard R#2 yell for help. HK D added she saw R#2 on the floor and she notified Certified Nurse Aide (CNA) F. HK D indicated R#2 never asked her to clean up any water. Witness statement dated 09/26/16 written by CNA F indicated she heard a loud thump then hollering went to the resident's room resident was on the floor bleeding from forehead. CNA F wrote she had notified the charge nurse and another CNA brought wash cloths to help stop the bleeding. CNA F added the resident told her she was cleaning the water off the floor herself because she had told the housekeeper and the housekeeper had told her to clean it up herself, then gave the resident a gown. Written statement dated 09/27/16 by HK E indicated she was walking down the 300 hall when passing by R#2's room, R#2 told her there was water on her floor and she had directed her to HK D and HK E kept walking down the hall. HK E statement indicated that sometime after 12:00 someone had said R#2 had fallen. Written statement by the Administrator dated 09/27/16 indicated HK E stated that R#2 told her there was water on her floor and HK E told R#2 there is (HK D) you need to tell her, and (R#2) said ok. Interview/Statement of HK D dated 09/27/16 written by the Administrator indicated HK D reported she had cleaned R#2's room around 7:30 a.m., while R#2 was at [MEDICAL TREATMENT], as she always did and that there was no water on the floor and had never seen water on R#2's floor. HK D stated that when R#2 returned from [MEDICAL TREATMENT], R#2 had told her that R#2 had spilled water inside of her refrigerator. HK D was passing clothes and she handed R#2 a hospital gown to soak up the water in the refrigerator and that R#2 never said water was on the floor. When asked why she gave her a gown instead of a towel, HK D stated she did not see any towels in the cart. HK D then stated that around 11:00 or 11:15 a.m., she was in the hallway and heard R#2 scream and HK D ran down to R#2's room and about the same time CNA F came into R#2's room and told HK D to get out. Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and HK D provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. During an interview with R#2 on 11/08/16 at 2:35 p.m., R#2 was observed to have a scar, approximately two inches in length on her forehead. R#2 reported she had gone to [MEDICAL TREATMENT] and when she returned to her room, somebody had taken a glass out of her personal refrigerator and there was lots of water on her floor. R#2 stated she tried to get HK D to clean up the water, but that HK D told her to wipe it up herself. R#2 stated she remembered falling and hitting her head, but did not know what she hit her head on. R#2 reported her forehead bled like crazy and it hurt. R#2 stated the staff thought there was something wrong with her refrigerator, but that someone had spilled the water that was in her refrigerator. Observation of the refrigerator indicated there were two large mugs with secure lids with water in her refrigerator. There were also two 14 ounce(oz) empty plastic glasses with a lid on a table. R#2 stated it was one of those 14 oz plastic glass that had spilled on the floor the day she fell . During an interview on 11/09/16 at 8:47 a.m., HK D stated she had worked at the facility for [AGE] years. HK D stated she was passing clothes in the 300 hall when R#2 told her there was water spilled inside her icebox. HK D stated she gave R#2 a gown and told her to put it inside the icebox, adding, she didn't tell me to come clean the spill. HK D added that common sense told her she should have gone to check the spill herself, but because she was busy passing out clothes and because R#2 said it was inside the icebox, and not on the floor, she did not go check for herself. HK D stated R#2 took the gown and left while the HK continued passing out the clean laundry. HK D stated that right away, she heard R#2 screaming and yelling and HK D went to R#2's room. HK D stated she was shocked and went blank when she saw R#2 on the floor. HK D said she too started yelling and that was when CNA F came into the room. HK D stated she had been suspended for a day and the Administrator told her she should have gone to see when R#2 notified her of the water spill. During an interview with CNA F on 11/09/16 at 9:13 a.m., CNA F stated she had not been aware that R#2 had returned from [MEDICAL TREATMENT], and she was in another room providing care. When CNA F walked out of the room, she heard a loud thump and someone screaming. CNA F stated R#2 was on the floor, bleeding and lots of blood was pouring out of her forehead. CNA F stated she hollered for the other CNA to bring her some towels to apply pressure to the laceration. CNA F stated she could see the bone on the resident's forehead. R#2 told her there was water on the floor and she had asked the HK to clean it up. R#2 told CNA F that the HK gave her a gown and said to clean it up herself. CNA F stated the floor was wet when she came into the room and the gown was on the floor, adding there was a lot of blood mixed with the water. CNA F stated R#2 told her she had left an open glass of water in the refrigerator and thought it had been spilled when her room was cleaned earlier that day. During a telephone interview on 11/09/16 at 10:00 a.m., HK E stated the day R#2 fell , HK E was on her lunch break. HK E stated she was walking down the 300 hall, on her way to lunch when R#2 told her there was water on the floor in her room. HK E stated she told R#2 that HK D was there and to tell her about the water spill. HK E added she had not gone into the room to see the water spill on the floor. HK E stated she got a write up and was inserviced, because she should have gone into the room to see about the spill. An IJ was determined to have existed from 09/26/16 through 09/29/16. The IJ was removed on 09/29/16 because observation, interview and record review indicated housekeeping and nursing staff had been in-serviced on safety in the workplace and potential hazards. The two housekeeping staff were also in-serviced individually and were disciplined in writing. The facility took the following action to correct the non-compliance: Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and (HK D) provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. The facility reported on 11/10/16 there were 24 residents in the facility who requires assistance with ambulation or assistive devices.

Based on observation, record review and interview, the facility failed to implement written policies and procedures that prohibit neglect for one Resident (R#2) out of nine residents reviewed for neglect. Housekeeping staff failed to clean up water on the floor in R#2's room as a result, R#2 fell and was transported to the emergency room and had sustained a laceration to the forehead requiring sutures. An Immediate Jeopardy (IJ) was determined to have existed from 09/26/16 to 09/29/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began. The Non-Compliance was removed on 09/29/16 when all staff was in-serviced on safety in the workplace and potential hazards. The houskeeping staff involved also received individual retraining and were disciplined. The failure to follow-up on potential hazards could affect 24 residents in the facility who requires assistance with ambulation or assistive devices. The findings were: R#2's Face Sheet dated 09/27/16 indicated R#2 was admitted to the facility on [DATE]. The Face Sheet indicated the latest return to the facility was 09/14/15. The Face Sheet indicated the resident was [AGE] years old. R#2's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#2 had clear speech; was usually understood and had the ability to usually understand others. R#2 was able to report the correct year, month and day. The MDS indicated R#2 was independent with no setup or physical help from staff for bed mobility, transfer, walk (with a walker) and toilet use. She did require supervision and setup help for dressing and personal hygiene. She also required setup help for eating. Active [DIAGNOSES REDACTED]. R#2's Care Plan, Start date: 08/04/15 indicated R#2 had the potential for falls, injuries due to the side effects of her depression medication. The Care Plan indicated that R#2 fell in her room due to water on the floor from her refrigerator and R#2 had sustained a laceration to the forehead. The resident was sent to the emergency room (ER) and had received sutures to the forehead. Physician Assistant (PA) C's Progress Note dated 09/27/16 indicated the resident fell in her room. The PA stated R#2 reported there was water on the floor and she had slipped. The note indicated the resident had gone to the ER the day before (09/26/16) for evaluation of a laceration to the forehead. R#2 had returned with several staples to her forehead. The note continued, She has ecchymosis (discoloration of the skin resulting from bleeding underneath) to her both eye sockets. Raccoon eyes will form over the next few days. I informed the patient her facial appearance will look worse but it will resolve in 3 weeks. The patient is stable today and as mentally as intact as when I last saw her 2 weeks ago. Provider Investigation Report dated 09/27/16 indicated the incident occurred on 09/26/16 at 11:00 a.m. in R#2's room. Incident Category was checked for Neglect. The report indicated R#2 required no special supervision; her functional ability was that she required minimal assistance; R#2 was independently ambulatory, interviewable and was not capable of making informed decisions. The report named two staff persons as alleged perpetrators (AP) which were identified by names and by interviews. The APs denied allegations according to the report. The description of the allegation was that R#2 fell in her room and she reported she had notified the housekeeper there was water on the floor and the housekeeper gave her a gown to soak up the water. The description of the injury was a fall resulting in sutures in the head. Description of the assessment was that pressure was applied to the [MEDICAL CONDITION] and R#2 was sent to the ER and returned at approximately 3:30 p.m. the same day. The Provider response was that the Physician and Responsible Party were notified; R#2 was sent to the ER; initiated investigation; counseling/inservices done; R#2's refrigerator was removed from her room to determine if water caused the spill or if the refrigerator was leaking. The investigation summary indicated R#2 had spilled water in her refrigerator; R#2 informed housekeeper (HK) D and R#2 was given a gown to soak up the water. HK E stated R#2 told her there was water on the floor, and HK E told R#2 to tell HK D. The report added R#2 was interviewable, but did not recall telling HK E. The investigation findings were inconclusive. Provider action taken post-investigation was that both housekeepers were counseled/inserviced and resident and staff interviews were done. Hospital Discharge Summary dated 09/26/16 at 2:19 p.m. indicated R#2 was treated for [REDACTED].#28 tablets 1 tablet every 12 hours. Follow-up notes indicated that on 09/26/16 R#2 was treated at the hospital and that sutures needed to be removed in seven days and the resident should return to the ER if symptoms worsened. Written statement dated 09/26/16 at 11:15 a.m. by HK D indicated HK D was passing out clothes on the 300 hall when she heard R#2 yell for help. HK D added she saw R#2 on the floor and she notified Certified Nurse Aide (CNA) F. HK D indicated R#2 never asked her to clean up any water. Witness statement dated 09/26/16 written by CNA F indicated she heard a loud thump then hollering went to the resident's room resident was on the floor bleeding from forehead. CNA F wrote she had notified the charge nurse and another CNA brought wash cloths to help stop the bleeding. CNA F added the resident told her she was cleaning the water off the floor herself because she had told the housekeeper and the housekeeper had told her to clean it up herself, then gave the resident a gown. Written statement dated 09/27/16 by HK E indicated she was walking down the 300 hall when passing by R#2's room, R#2 told her there was water on her floor and she had directed her to HK D and HK E kept walking down the hall. HK E statement indicated that sometime after 12:00 someone had said R#2 had fallen. Written statement by the Administrator dated 09/27/16 indicated HK E stated that R#2 told her there was water on her floor and HK E told R#2 there is (HK D) you need to tell her, and (R#2) said ok. Interview/Statement of HK D dated 09/27/16 written by the Administrator indicated HK D reported she had cleaned R#2's room around 7:30 a.m., while R#2 was at [MEDICAL TREATMENT], as she always did and that there was no water on the floor and had never seen water on R#2's floor. HK D stated that when R#2 returned from [MEDICAL TREATMENT], R#2 had told her that R#2 had spilled water inside of her refrigerator. HK D was passing clothes and she handed R#2 a hospital gown to soak up the water in the refrigerator and that R#2 never said water was on the floor. When asked why she gave her a gown instead of a towel, HK D stated she did not see any towels in the cart. HK D then stated that around 11:00 or 11:15 a.m., she was in the hallway and heard R#2 scream and HK D ran down to R#2's room and about the same time CNA F came into R#2's room and told HK D to get out. Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and HK D provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. During an interview with R#2 on 11/08/16 at 2:35 p.m., R#2 was observed to have a scar, approximately two inches in length on her forehead. R#2 reported she had gone to [MEDICAL TREATMENT] and when she returned to her room, somebody had taken a glass out of her personal refrigerator and there was lots of water on her floor. R#2 stated she tried to get HK D to clean up the water, but that HK D told her to wipe it up herself. R#2 stated she remembered falling and hitting her head, but did not know what she hit her head on. R#2 reported her forehead bled like crazy and it hurt. R#2 stated the staff thought there was something wrong with her refrigerator, but that someone had spilled the water that was in her refrigerator. Observation of the refrigerator indicated there were two large mugs with secure lids with water in her refrigerator. There were also two 14 ounce(oz) empty plastic glasses with a lid on a table. R#2 stated it was one of those 14 oz plastic glass that had spilled on the floor the day she fell . During an interview on 11/09/16 at 8:47 a.m., HK D stated she had worked at the facility for [AGE] years. HK D stated she was passing clothes in the 300 hall when R#2 told her there was water spilled inside her icebox. HK D stated she gave R#2 a gown and told her to put it inside the icebox, adding, she didn't tell me to come clean the spill. HK D added that common sense told her she should have gone to check the spill herself, but because she was busy passing out clothes and because R#2 said it was inside the icebox, and not on the floor, she did not go check for herself. HK D stated R#2 took the gown and left while the HK continued passing out the clean laundry. HK D stated that right away, she heard R#2 screaming and yelling and HK D went to R#2's room. HK D stated she was shocked and went blank when she saw R#2 on the floor. HK D said she too started yelling and that was when CNA F came into the room. HK D stated she had been suspended for a day and the Administrator told her she should have gone to see when R#2 notified her of the water spill. During an interview with CNA F on 11/09/16 at 9:13 a.m., CNA F stated she had not been aware that R#2 had returned from [MEDICAL TREATMENT], and she was in another room providing care. When CNA F walked out of the room, she heard a loud thump and someone screaming. CNA F stated R#2 was on the floor, bleeding and lots of blood was pouring out of her forehead. CNA F stated she hollered for the other CNA to bring her some towels to apply pressure to the laceration. CNA F stated she could see the bone on the resident's forehead. R#2 told her there was water on the floor and she had asked the HK to clean it up. R#2 told CNA F that the HK gave her a gown and said to clean it up herself. CNA F stated the floor was wet when she came into the room and the gown was on the floor, adding there was a lot of blood mixed with the water. CNA F stated R#2 told her she had left an open glass of water in the refrigerator and thought it had been spilled when her room was cleaned earlier that day. During a telephone interview on 11/09/16 at 10:00 a.m., HK E stated the day R#2 fell , HK E was on her lunch break. HK E stated she was walking down the 300 hall, on her way to lunch when R#2 told her there was water on the floor in her room. HK E stated she told R#2 that HK D was there and to tell her about the water spill. HK E added she had not gone into the room to see the water spill on the floor. HK E stated she got a write up and was inserviced, because she should have gone into the room to see about the spill. The facility's Policy and Procedure, Subject Abuse-Reportable Events revised date: 08/2016 indicated that neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was determined to have existed from 09/26/16 through 09/29/16. The IJ was removed on 09/29/16 because observation, interview and record review indicated housekeeping and nursing staff had been in-serviced on safety in the workplace and potential hazards. The two housekeeping staff were also in-serviced individually and were disciplined in writing. The facility took the following action to correct the non-compliance: Notice of Disciplinary Action on HK E date of violation 09/26/16 indicated HK E had violated policy when R#2 notified her the floor was wet and HK E referred her to HK D, exposing R#2, staff and family members to a safety hazard. The notice was signed by HK E on 09/29/16. Note of Disciplinary Action on HK D date of violation 09/26/16 indicated HK D had violated policy when R#2 notified her of a water spill in her refrigerator and (HK D) provided her a material to clean it up, exposing the resident, staff and visitors to a safety hazard. Inservice Training Report, Subject: Safety in the Workplace and Potential Hazards cause Harm dated 09/29/16 at 9:00 a.m. and 2:00 p.m. indicated all housekeeping and nursing staff received the training. Maintenance Work Order Request dated 09/27/16 indicated all refrigerators in the building were checked and no leaks or damaged refrigerators were found. The facility reported on 11/10/16 there were 24 residents in the facility who requires assistance with ambulation or assistive devices.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for six Residents (R #1, R #3, R #4, R #9, R #10, R #11) of 16 Residents reviewed for hydration and infections. The Administrator failed to: 1) Implement policies and procedures for hydration, and intake and output. 2) Supervise the DON by using the Quality Assurance process, making rounds, and following up with concerns. The DON was aware that R #1 was at risk of dehydration but failed to ensure effective interventions were in place to protect R #1. The DON failed to: 1) Implement policies and procedures for hydration, and intake and output. 2) Put effective measures into place to ensure staff followed care plans. 3) Supervise the nursing staff to ensure that the nursing staff were consistently assessing R #1 and consistently documenting those assessments. R #1 had a recent hospitalization with a [DIAGNOSES REDACTED].#1's condition. As a result of this, R #1 was sent to the hospital [MEDICAL CONDITION], dehydration and pus in his urine. R #1 was discharged to another facility from the hospital with hospice. The facility was aware that R #3, R #4, R #9, R #10 and R #11 were at risk for dehydration and did not consistently monitor and document those residents' conditions. These failures resulted in identification of an Immediate Jeopardy (IJ) on 05/08/14 at 10:50 a.m. While the IJ was removed on 05/09/14 at 12:15 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed 16 residents with [DEVICE]s, seven residents with indwelling urinary catheters and 123 residents with hydration issues at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to Facility "DD" on 01/23/13 with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 had no speech; rarely/never made self understood; sometimes understood others; had a moderately impaired cognition (decisions poor; cues/supervision required); was totally dependent on staff for eating, toilet use, bed mobility, locomotion, personal hygiene and bathing; was always incontinent of bowel and bladder; was not dehydrated; received oxygen therapy; had a feeding tube; received 51% or more nutrition through a feeding tube; and received 501 cc/day or more fluid intake through a feeding tube. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Dehydration/Fluid Maintenance. R #1's Care Plan dated 02/28/14 revealed: -"Care Plan for Residents with risks for Dehydration...Monitor s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids [DEVICE] as ordered..." R #1's Consolidated Physician order [REDACTED]. -03/13/14: "[MEDICATION NAME] (liquid nutrition via [DEVICE]) to infuse at 55cc/hr x 22hrs/day...to provide...949cc free H2O..." -04/09/13: "Flush [DEVICE] with 180cc H2O q4h..." -11/14/13: "Flush [DEVICE] with a least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -Magnesium oxide (supplement) 400mg TID. SE: electrolyte, fluid imbalances. -[MEDICATION NAME] (anticonvulsant) 250mg=10mL TID. SE: [MEDICAL CONDITION] (inflammation of the kidneys.) -Trazadone (antidepressant) 25mg BID. SE: Acute [MEDICAL CONDITION]. According to Lippincott's 2013 Nursing Procedures, Sixth Edition, page 729, documentation for gastrostomy tube feeding and complications included: -"On the intake and output record (I&O), note the date, time, and amount of each feeding and the water volume instilled..." -"Maintain total volumes for nutrients and water separately to allow calculation of nutrient intake..." -"In your notes, document the type of formula, the infusion method and rate, the patient's tolerance of the procedure and formula, and the amount of residual gastric contents..." -"...complications include...fluid and electrolyte imbalances..." R #1's "Enteral Flowsheets", "Enteral Meds Flowsheets", and "Medications Flowsheets" dated 04/2014 and 05/2014 revealed no documentation of R #1's total intake of tube feeding formula and water volumes instilled. R #1's ADL Flowsheets dated 04/2014 and 05/2014 revealed R #1 was "wet" three times on each shift: 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. The ADL Flowsheets did not describe what "wet" represented. R #1's Nurses Notes revealed the following entries dated 04/01/14: -1:30 a.m.: "Found resident responsed (sic) not like used to. Check v/s (BP) 72/48, (T) 97.3, (P) 80, (R) 22...Called (physician)..." -1:55 a.m.: "...Resident is transferred to (Hospital "AA")..." -5:00 a.m.: "Resident came back from (Hospital "AA")...(with) new ordered (antibiotic)...still not response (sic) well this time..." R #1's Discharge Summary dated 04/01/14 from Hospital "AA" revealed R #1's [DIAGNOSES REDACTED]. R #1's Nurses Notes and Monthly Summary revealed the following: Nurses Notes: -From 04/13/14 at 5:00 p.m. through 04/17/14 at 2:00 p.m. revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 3 days and 21 hours. -From 04/20/14 at 6:00 p.m. through 04/26/14 until 10:00 a.m. revealed no documentation of R #1's condition, approximately 5 days and 16 hours. -From 04/29/14 at 2:23 p.m. through 05/05/14 until 2:30 a.m. revealed no documentation of R #1's condition, approximately 5 days and 12 hours. -05/05/14 at 2:30 a.m.: "Upon entering room, found resident'[MEDICAL CONDITION] large amount of coffee brown emesis (with) phlegm. Suction given @ this time. 02 sat 81% @ 3 LPM...Check v/s (T) 100.9, (BP) 100/67, (P) 91, (R) 24. Tylenol 650mg gave @ this time..." -2:45 a.m.: The physician was called regarding R #1's condition. -3:10 a.m.: "Call 911 to transfer resident to (Hospital "AA")..." -3:15 a.m.: "911 staff here to transfer resident to (Hospital "AA")..." Monthly Summary dated 05/01/14: -"Dry Skin" and "Mucous Membrane Moist." According to the American Medical Directors Association, www.amda.com, retrieved on 05/16/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Provider Report dated 05/05/14 from Hospital "AA" revealed: -3:49 a.m.: BP 89/65, P 85, R 16, T 99.3 -3:51 a.m.: "...lethargic, dehydrated..." -7:11 a.m.: BP 77/53, P 73, R 20, T 100.4 at 6:00 a.m. R #1's History and Physical dated 05/05/14 from Hospital "AA" revealed R #1 was diagnosed with [REDACTED]. R #1's Clinical Note dated 05/05/14 from Hospital "AA" revealed: -12:34 p.m.: "...After insertion of the (indwelling catheter) 300cc of purulent (pus) urine was returned..." -7:28 p.m.: "...Pt was admitted to ICU..." According to www.sepsisalliance.org on 05/12/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 05/12/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's Laboratory Test results dated 05/05/14 from Hospital "AA" revealed: Urinalysis: -"Urine appearance HAZY" Normal range "CLEAR." -"Urine pH 8.0 H" Normal range 5.5-7.0. -"Urine Protein 25 H" Normal range "NEGATIVE." -"Urine Blood 1+ H" Normal range "NEGATIVE." -"Urine [MEDICATION NAME] POSITIVE H" Normal range "NEGATIVE." -"(Urine) Leukocyte Esterase 2+ H" Normal range "NEGATIVE." -"Urine WBC 5-10 H" Normal range "NONE SEEN." -"(Urine) Transition Epith Cell FEW H" Normal range "NONE SEEN." -"Urine Bacteria 1+" Normal range "NONE SEEN." The Urinalysis dated 05/05/14 indicated R #1 had the potential to have a urinary tract infection. Blood Chemistry: -"BUN 21 H" Normal range 6-20. -"Glucose 135 H" Normal range 65-99. The Blood Chemistry dated 05/05/14 indicated R #1 had the potential to be dehydrated. R #1's Hospitalist Progress Note dated 05/06/14 from Hospital "AA" revealed: -24 hour total intake was 2085cc and total output was 855cc. -"...prognosis is very poor for this patient..." Observation on 05/07/14 at 10:20 a.m., at Hospital "AA", revealed R #1 lying in bed in ICU and unresponsive to surveyor's questions. On 05/07/14 at 10:25 a.m., MD "CC" from Hospital "AA" stated R #1 was "dehydrated" when admitted to the hospital on [DATE] and "[MEDICAL CONDITION] criteria." MD "CC" stated R #1's prognosis was "poor." On 05/08/14 at 11:00 a.m., SW "BB" from Hospital "AA" stated R #1 was discharged to another facility with hospice. The following information was gathered at Facility "DD": On 05/08/14 at 8:00 a.m., LVN "V" stated it was not the facility's policy to document or monitor a resident's intake and output, except for "fluid restriction." LVN "V" stated a resident's skin turgor and vital signs should be monitored to assess for dehydration and that if something was not "written down (in the nurses notes), it didn't happen." Surveyor asked LVN "V" how he would know a resident was at risk for dehydration. LVN "V" stated he would know by a resident's diagnosis. On 05/08/14 at 8:25 a.m., CNA "W" stated it was not the facility's policy to document or monitor a resident's intake and output. CNA "W" stated monitoring intake and output "should be done for residents" who were at risk for dehydration because a resident "could get dehydrated, decline in health, (and) organs won't work correctly." CNA "W" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "W" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:10 a.m., CNA "Y" stated it was not the facility's policy to document or monitor a resident's intake and output. Surveyor asked CNA "Y" how she would know a resident was at risk for dehydration. CNA "Y" stated a resident's ADL Flowsheet would alert staff that a resident was at risk for dehydration if the resident had "nectar liquids." CNA "Y" stated a resident who was dehydrated could get a "UTI" and "go to the hospital." CNA "Y" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "Y" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:25 a.m., CNA "X" stated residents who were at risk for dehydration were "monitored by the nurses." On 05/08/14 at 9:55 a.m., the DON stated nurses would know a resident was at risk for dehydration if the resident had "been in the hospital," nurses would "look at the whole picture," document the resident's condition on the "24 Hour Report" and do a "head to toe assessment." The DON stated the CNAs would know a resident was at risk for dehydration by looking at the "Care Plan" and "from the nurses." The DON stated, "It's a nursing thing to know if a resident is at risk for dehydration. We will monitor the resident." Surveyor asked the DON how staff monitored residents at risk for dehydration. The DON stated, "It depends on the resident. Nurses make rounds to monitor residents for dehydration...All residents are at risk for dehydration or they wouldn't be here." On 05/07/14 at 12:25 p.m., the DON stated the facility did not document or monitor resident's intake and output unless there was a physician's orders [REDACTED]." Review of the facility's 24 Hour Reports dated 04/24/14 through 05/05/14 revealed no documentation regarding R #1's hydration status. On 05/09/14 at 9:15 a.m., LVN "Z" stated it was not the facility's policy to monitor a resident's intake and output and staff "haven't done it." LVN "Z" stated, "I feel it's important to monitor (intake and output). A resident could get confused, a resident could die because of dehydration [MEDICAL CONDITION]." Surveyor asked LVN "Z" how she would know a resident was at risk for dehydration. LVN "Z" stated, "I don't know how I would know." LVN "Z" stated she would assess for dehydration by "dry skin, low output, mental status" and "would put it in the nurses notes. It should at least be charted every shift when there is a problem." On 05/09/14 at 9:40 a.m., LVN "A" stated a resident who was at risk for dehydration should be assessed for "change in status, sunken eyes, skin turgor" and there "should be charting to know if (a resident was) assessed for dehydration." On 05/09/14 at 11:35 a.m., in response to surveyor's question regarding how the IJ came about, the DON stated, "I don't understand how it came about. I made rounds and the administrative nurses made daily rounds to ensure residents were hydrated, (along with) the Dietician." On 05/09/14 at 11:55 a.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "Based on what you (surveyor) said. I think we do have processes in place to monitor that (hydration)." The Administrator stated she monitored the DON "through the Quality Assurance process, rounds (and) follow-up with concerns." R #3 R #3's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]., Cerebral Vascular Disease, Basal Ganglia Degeneration ([MEDICAL CONDITION] that fails to suppress unwanted movements), Paralytic Ileus (intestinal paralysis), Intestinal Obstruction, Tracheotomy, [MEDICAL CONDITION], Constipation, Dementia, Vascular Urinary Obstruction, Diarrhea and [MEDICAL CONDITION]. R #3's Quarterly MDS dated [DATE] revealed R #3 was unable to speak, rarely/never understood others nor was understood by others, had long and short term memory problems, was totally dependent with all ADLs and required the assistance of two persons with dressing and transfers, was incontinent of urine and had an [MEDICAL CONDITION] for bowel movements, tube feeding; received 51% or more nutrition through a [DEVICE] feedings; and received 501 cc/day or more fluid intake through a feeding tube, received oxygen therapy, tracheotomy care and suctioning. R #3's Nursing Assistant Care Plan dated 11/12/13 "Nutritional Status" revealed R #3 had a "tube feeder" and was incontinent of urine and had a [MEDICAL CONDITION]. R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed R #3: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 2:00 p.m.-10:00 p.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed an additional [DIAGNOSES REDACTED]." R #3's Care Plans dated 03/17/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T Dysphagia and [DEVICE] use .....Goal: Residents Nutritional Status will be maintained, Resident will have measures to decrease the potential of ...Dehydration ... Approach: Monitor for Signs and Symptoms of Dehydration, Dry Mucus Membranes, Decreased Output, changes in LOC, Change in Lab Values ..... ...Potential For Impaired Urinary Flow D/T HX. Urethral Obstruction ... Goal ...Resident Will Not Experience any Obstruction of Urinary Flow By Next Review ...Approach ...Monitor For Adequate Urinary Output Lower ABD Distention or Discomfort." R #3's Nurses Notes dated 03/20/14 through 05/08/14 revealed no documentation reflecting R #3 was assessed for Dehydration or Urinary Output. R #3's Nutritional Progress Note dated 03/28/14 revealed R #3 was NPO (nothing by mouth) and received [DEVICE] feedings with "[MEDICATION NAME]" (liquid nutrition) at 40 cc/hr for 22 hours and flushed with 340 cc of water every four hours. R #3's Monthly Summary dated 04/21/14 revealed: "Eating ...Total Dependence Why is this support needed: Tube Feeding due to volume depletion, dehydration, [MEDICAL CONDITION]." R #3's Laboratory Report dated 04/17/14 revealed: -Urea Nitrogen-29 H Reference range (7-25) -Creatinine-1.4 H Reference range (0.7-1.3). -eGFR-49 L Reference range (90>) The Laboratory Report dated 04/17/14 indicated R #3 had the potential to be dehydrated. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE], with the following Diagnoses: [REDACTED]. R #4's MDS dated [DATE] revealed R #4 was rarely/never understood by others nor understood others; cognitive skills for daily decision making were severely impaired-never/rarely made decisions; had total dependence with bed mobility and transfers and required two person assist; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; received 501 cc/day or more fluid intake through a [DEVICE]; had two stage two Pressure Ulcers; and medication included a diuretic. R #4's Nursing Assistant Care Plan dated 11/11/13 revealed: -"Nutritional Status" section revealed R #4 had [DEVICE] and was NPO, -"Elimination-Bladder, Elimination- Bowel" section revealed R #4 was incontinent of urine and bowel, -"Diet" section revealed R #4 had [MEDICAL CONDITION] feeding @35cc/hr. Flush with water per M.D. Orders. R #4's ADL Flow Sheet dated 05/01/14 through 05/31/14 revealed R #4: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 10:00 pm.-6:00 a.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #4's Care Plan dated 03/11/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T [DEVICE] Fed, NPO, and Dependent on Others for Nutrition and Hydration. .....Goal: Resident will have Measures to maintain Nutritional Status, be well Hydrated... Approach: Monitor for Dry Mucus Membranes, Fever, Poor Skin Turgor, Change in LOC, Changes in Lab Values." R #4's Care Plan entitled "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "-Goal: Consume Adequate Fluids -Approaches: Monitor s/s of dehydration, poor skin turgor, dry mucus membranes, offer fluids per GT, Monitor for [MEDICAL CONDITION]/dyspnea, Labs as ordered, Educate resident and/or family." R #4's Nurses Notes dated 11/05/13 through 05/06/14 revealed no documentation reflecting R #4 was assessed for Dehydration or Urinary Output. R #4's Consolidated Physician order [REDACTED]. R #4 had an order for [REDACTED]. Flush GT with 150cc of water every four hours. According to Mosby's 25th Edition: Nursing Drug Reference; [MEDICATION NAME] had the following precautions:...."dehydration." R #9 R #9's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. R #9's consolidated Physician order [REDACTED]. Once a day on the 15th of the month; 11:00 p.m.-7:00 a.m." R #9's Admission Care Plan dated 12/31/13 revealed; "Dehydration/Fluid Maintenance - Goal: Resident will consume adequate fluids..... - Monitor for signs/symptoms of dehydration... - Laboratory work as ordered... UTI FC (Urinary tract Infection/Urinary Catheter) - Goal: Resolve -Monitor every shift for UTI symptoms - Intake and Output." R #9's Laboratory Report dated 01/08/14 revealed: -Chloride-108 H (high) Reference range (98-107) previous results 08/24/13-101, -Urea Nitrogen-33 H Reference range (7-25) previous results 8/24/13-16, -Creatinine-1.5 H Reference range (0.7-1.3) previous results 8/24/13-1.1, -Osmolarity-293 H Reference range (260-278) previous results 8/24/13-277, -eGFR-44 L (low) Reference range (90>) (greater than 90) previous results 8/24/13-63. The Laboratory Report dated 01/08/14 indicated R #1 had the potential to be dehydrated. R #9's Care Plans dated 01/10/14 revealed there were no care plans specific to monitoring Intake and Output or Dehydration. R #9's Quarterly MDS dated [DATE] revealed R #9 had difficulty hearing, was sometimes understood and sometimes understood others, vision was moderately impaired,had both short and long term memory problems, cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required, required the assistance of two persons for transfers, required set up for meals, had an indwelling urinary catheter and a [MEDICAL CONDITION], and two unstageable decubitus ulcers. R #9's undated Nursing Assistant Care Plan regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan, but there was no specific care provision documented. R #9's Nursing Assistant Care Plan dated 05/01/14 regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan with specific instruction "I&O's Q shift." R #9's undated Summary/Registered Dietician Recommendations estimated fluid intake was 2000-2400 cc of fluids per day. R #9's medical record did not have any documentation revealing amount of fluid intake. R #9's ADL Flow Sheets revealed: 04/01/14-04/30/14: -There was no documentation for the entire month, on the 6:00 a.m.-2:00 p.m. shift for urine output measurement. - 04/06/14 through 04/08/14, there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. - 04/14/14 and 04/16/14 there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. Dated 05/01/14-05/31/14: -There was no documentation 05/01/14-05/06/14, on the 6:00 a.m.-2:00 p.m. or the 2:00 p.m.-10:00 p.m. shift. for urine output measurement. - 05/02/14 total documented urine output was 400 (no units of measurements noted). - 05/16/14 total urine output documented was 500. (no units of measurements noted). - 05/07/14 and 05/30/14 there was 600 total urine output documented.(no units of measurements noted). According to Lippincott's Nursing Procedures, 6th Edition, pages 376 and 377: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." On 05/09/14 at 9:30 a.m., LVN "M" said the policy of the facility was to monitor Intake and Output on residents with indwelling urinary catheters because of complications related to indwelling catheters such as obstruction, infection or dislodgement. The CNAs emptied the urinary catheter bags at the end of the shift and documented the output amount on the ADL sheet. The LVN "M" said, if the Output was not documented on the ADL sheet then the nurses would not be able to track how much out put that resident had for the shift. LVN "M" said, "if a resident were to become dehydrated or septic they would become delirious, get really sick and die and that (LVN "M") has seen a resident at the facility, become dehydrated in the past." LVN "M" said, "hydration was of top priority because people need fluids to stay alive." On 05/09/14 at 9:55 a.m., CNA "L" said that prior to yesterday the staff never had any formal training at the facility in measuring Intakes and Outputs for residents with urinary catheters. The CNA's knew what care to provide each resident by following the Nursing Assistant Care Plan. On 05/09/14 at 10:10 a.m., CNA "K" said, the CNA's were supposed to encourage residents to drink fluids. The CNAs were to empty out urinary catheter bags every shift and document on the resident's individual ADL sheet how much the resident urinated for that shift. If a resident became dehydrated, that could lead to constipation. On 05/09/14 at 1030 a.m., LVN "P" said the nurses were supposed to document in the nurses notes, and on the Intake and Output book all Intake and Outputs on residents with urinary catheters and residents that received [DEVICE] feedings. Residents at risk for dehydration were residents with dementia, [MEDICAL TREATMENT], thickened liquids. For Residents without urinary catheters the staff measured the Output by how many times the diaper had been changed, and if diaper was wet or soaked. The CNAs were to report any change in resident urination pattern, dark colored urine or foul odor to the nurse. The CNAs also emptied the urine bags every shift and documented the amount of output in the ADL sheet. If the CNAs were to not document how much out put the resident had at the end of the shift there would not be anyway for the nurses to know if the resident had voided. If a resident doesn't have adequate hydration they could become dehydrated and eventually expire. On 05/09/14 at 10:50 a.m., CNA"N"said, staff were in-serviced yesterday on how to determine if a resident was dehydrated. CNA"N"said, if a resident was dehydrated, the resident would be confused, not urinate and have poor skin elasticity. Residents with urinary catheters, the CNAs were supposed to write down the urine output every shift in the ADL book. The nurses and the aides would keep track of how much fluid the residents consumed by observing the meal trays to track how much the resident drank and encourage fluid intake. The CNAs knew what care to provide each resident by following the Nursing Assistant Care Plan. R #10 R #10's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #10's Quarterly MDS dated [DATE] revealed R #10 usually understood others and made self understood; had inattention and disorganized thinking; was independent with eating; was always continent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #10's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor for s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids - To nectar consistency. Resident has [DEVICE] (with) feeding @ HS...Monitor for [MEDICAL CONDITION]/dyspnea (swelling/air hunger..." R #10's Physician order [REDACTED]. -Regular diet with nectar thick liquids, -Offer 6-8 ounces of water thickened to nectar consistency four times a day with med pass, -Flush [DEVICE] with 150cc water every four hours, -Per [DEVICE]: "[MEDICATION NAME] 1.5 Cal (liquid nutrition) to infuse at 75cc/hr via pump x 10 hrs/day (8pm-6am) to provide...570cc free H2O..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." R #10's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #10's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #10's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #10's Nurses Notes revealed: -Dated 04/08/14 through 04/17/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. -There was no documentation from 04/17/14 through 04/23/14, approximately six days. -There was no documentation from 04/24/14 through 04/28/14, approximately four days. -There was no documentation from 04/29/14 through 05/02/14, approximately four days. -Dated 05/03/14 through 05/08/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. R #11 R #11's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #11's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor s/s of dehydration (poor skin turgor, dry mucous membranes,) Offer Fluids - To nectar consistency. Resident also receives feedings per [DEVICE]...Monitor for [MEDICAL CONDITION]/dyspnea..." R #11's Annual MDS dated [DATE] revealed R #11 sometimes understood others and sometimes made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); had inattention and disorganized thinking; was totally

Based on observation, interview and record review the facility failed to implement their policy and procedure that prohibits neglect for six Residents (R #1, R #3, R #4, R #9, R #10, R #11) of 16 Residents reviewed for hydration and infections. R #1 had a recent hospitalization with a [DIAGNOSES REDACTED].#1's condition. As a result of this, R #1 was sent to the hospital [MEDICAL CONDITION], dehydration and pus in his urine. R #1 was discharged to another facility from the hospital with hospice. The facility was aware that R #3, R #4, R #9, R #10 and R #11 were at risk for dehydration and did not consistently monitor and document those residents' conditions. These failures resulted in identification of an Immediate Jeopardy (IJ) on 05/08/14 at 10:50 a.m. While the IJ was removed on 05/09/14 at 12:15 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed 16 residents with [DEVICE]s, seven residents with indwelling urinary catheters and 123 residents with hydration issues at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to Facility "DD" on 01/23/13 with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 had no speech; rarely/never made self understood; sometimes understood others; had a moderately impaired cognition (decisions poor; cues/supervision required); was totally dependent on staff for eating, toilet use, bed mobility, locomotion, personal hygiene and bathing; was always incontinent of bowel and bladder; was not dehydrated; received oxygen therapy; had a feeding tube; received 51% or more nutrition through a feeding tube; and received 501 cc/day or more fluid intake through a feeding tube. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Dehydration/Fluid Maintenance. R #1's Care Plan dated 02/28/14 revealed: -"Care Plan for Residents with risks for Dehydration...Monitor s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids [DEVICE] as ordered..." R #1's Consolidated Physician order [REDACTED]. -03/13/14: "[MEDICATION NAME] (liquid nutrition via [DEVICE]) to infuse at 55cc/hr x 22hrs/day...to provide...949cc free H2O..." -04/09/13: "Flush [DEVICE] with 180cc H2O q4h..." -11/14/13: "Flush [DEVICE] with a least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -Magnesium oxide (supplement) 400mg TID. SE: electrolyte, fluid imbalances. -[MEDICATION NAME] (anticonvulsant) 250mg=10mL TID. SE: [MEDICAL CONDITION] (inflammation of the kidneys.) -Trazadone (antidepressant) 25mg BID. SE: Acute [MEDICAL CONDITION]. According to Lippincott's 2013 Nursing Procedures, Sixth Edition, page 729, documentation for gastrostomy tube feeding and complications included: -"On the intake and output record (I&O), note the date, time, and amount of each feeding and the water volume instilled..." -"Maintain total volumes for nutrients and water separately to allow calculation of nutrient intake..." -"In your notes, document the type of formula, the infusion method and rate, the patient's tolerance of the procedure and formula, and the amount of residual gastric contents..." -"...complications include...fluid and electrolyte imbalances..." R #1's "Enteral Flowsheets", "Enteral Meds Flowsheets", and "Medications Flowsheets" dated 04/2014 and 05/2014 revealed no documentation of R #1's total intake of tube feeding formula and water volumes instilled. R #1's ADL Flowsheets dated 04/2014 and 05/2014 revealed R #1 was "wet" three times on each shift: 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. The ADL Flowsheets did not describe what "wet" represented. R #1's Nurses Notes revealed the following entries dated 04/01/14: -1:30 a.m.: "Found resident responsed (sic) not like used to. Check v/s (BP) 72/48, (T) 97.3, (P) 80, (R) 22...Called (physician)..." -1:55 a.m.: "...Resident is transferred to (Hospital "AA")..." -5:00 a.m.: "Resident came back from (Hospital "AA")...(with) new ordered (antibiotic)...still not response (sic) well this time..." R #1's Discharge Summary dated 04/01/14 from Hospital "AA" revealed R #1's [DIAGNOSES REDACTED]. R #1's Nurses Notes and Monthly Summary revealed the following: Nurses Notes: -From 04/13/14 at 5:00 p.m. through 04/17/14 at 2:00 p.m. revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 3 days and 21 hours. -From 04/20/14 at 6:00 p.m. through 04/26/14 until 10:00 a.m. revealed no documentation of R #1's condition, approximately 5 days and 16 hours. -From 04/29/14 at 2:23 p.m. through 05/05/14 until 2:30 a.m. revealed no documentation of R #1's condition, approximately 5 days and 12 hours. -05/05/14 at 2:30 a.m.: "Upon entering room, found resident'[MEDICAL CONDITION] large amount of coffee brown emesis (with) phlegm. Suction given @ this time. 02 sat 81% @ 3 LPM...Check v/s (T) 100.9, (BP) 100/67, (P) 91, (R) 24. Tylenol 650mg gave @ this time..." -2:45 a.m.: The physician was called regarding R #1's condition. -3:10 a.m.: "Call 911 to transfer resident to (Hospital "AA")..." -3:15 a.m.: "911 staff here to transfer resident to (Hospital "AA")..." Monthly Summary dated 05/01/14: -"Dry Skin" and "Mucous Membrane Moist." According to the American Medical Directors Association, www.amda.com, retrieved on 05/16/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Provider Report dated 05/05/14 from Hospital "AA" revealed: -3:49 a.m.: BP 89/65, P 85, R 16, T 99.3 -3:51 a.m.: "...lethargic, dehydrated..." -7:11 a.m.: BP 77/53, P 73, R 20, T 100.4 at 6:00 a.m. R #1's History and Physical dated 05/05/14 from Hospital "AA" revealed R #1 was diagnosed with [REDACTED]. R #1's Clinical Note dated 05/05/14 from Hospital "AA" revealed: -12:34 p.m.: "...After insertion of the (indwelling catheter) 300cc of purulent (pus) urine was returned..." -7:28 p.m.: "...Pt was admitted to ICU..." According to www.sepsisalliance.org on 05/12/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 05/12/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's Laboratory Test results dated 05/05/14 from Hospital "AA" revealed: Urinalysis: -"Urine appearance HAZY" Normal range "CLEAR." -"Urine pH 8.0 H" Normal range 5.5-7.0. -"Urine Protein 25 H" Normal range "NEGATIVE." -"Urine Blood 1+ H" Normal range "NEGATIVE." -"Urine [MEDICATION NAME] POSITIVE H" Normal range "NEGATIVE." -"(Urine) Leukocyte Esterase 2+ H" Normal range "NEGATIVE." -"Urine WBC 5-10 H" Normal range "NONE SEEN." -"(Urine) Transition Epith Cell FEW H" Normal range "NONE SEEN." -"Urine Bacteria 1+" Normal range "NONE SEEN." The Urinalysis dated 05/05/14 indicated R #1 had the potential to have a urinary tract infection. Blood Chemistry: -"BUN 21 H" Normal range 6-20. -"Glucose 135 H" Normal range 65-99. The Blood Chemistry dated 05/05/14 indicated R #1 had the potential to be dehydrated. R #1's Hospitalist Progress Note dated 05/06/14 from Hospital "AA" revealed: -24 hour total intake was 2085cc and total output was 855cc. -"...prognosis is very poor for this patient..." Observation on 05/07/14 at 10:20 a.m., at Hospital "AA", revealed R #1 lying in bed in ICU and unresponsive to surveyor's questions. On 05/07/14 at 10:25 a.m., MD "CC" from Hospital "AA" stated R #1 was "dehydrated" when admitted to the hospital on [DATE] and "[MEDICAL CONDITION] criteria." MD "CC" stated R #1's prognosis was "poor." On 05/08/14 at 11:00 a.m., SW "BB" from Hospital "AA" stated R #1 was discharged to another facility with hospice. The following information was gathered at Facility "DD": On 05/08/14 at 8:00 a.m., LVN "V" stated it was not the facility's policy to document or monitor a resident's intake and output, except for "fluid restriction." LVN "V" stated a resident's skin turgor and vital signs should be monitored to assess for dehydration and that if something was not "written down (in the nurses notes), it didn't happen." Surveyor asked LVN "V" how he would know a resident was at risk for dehydration. LVN "V" stated he would know by a resident's diagnosis. On 05/08/14 at 8:25 a.m., CNA "W" stated it was not the facility's policy to document or monitor a resident's intake and output. CNA "W" stated monitoring intake and output "should be done for residents" who were at risk for dehydration because a resident "could get dehydrated, decline in health, (and) organs won't work correctly." CNA "W" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "W" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:10 a.m., CNA "Y" stated it was not the facility's policy to document or monitor a resident's intake and output. Surveyor asked CNA "Y" how she would know a resident was at risk for dehydration. CNA "Y" stated a resident's ADL Flowsheet would alert staff that a resident was at risk for dehydration if the resident had "nectar liquids." CNA "Y" stated a resident who was dehydrated could get a "UTI" and "go to the hospital." CNA "Y" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "Y" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:25 a.m., CNA "X" stated residents who were at risk for dehydration were "monitored by the nurses." On 05/08/14 at 9:55 a.m., the DON stated nurses would know a resident was at risk for dehydration if the resident had "been in the hospital," nurses would "look at the whole picture," document the resident's condition on the "24 Hour Report" and do a "head to toe assessment." The DON stated the CNAs would know a resident was at risk for dehydration by looking at the "Care Plan" and "from the nurses." The DON stated, "It's a nursing thing to know if a resident is at risk for dehydration. We will monitor the resident." Surveyor asked the DON how staff monitored residents at risk for dehydration. The DON stated, "It depends on the resident. Nurses make rounds to monitor residents for dehydration...All residents are at risk for dehydration or they wouldn't be here." On 05/07/14 at 12:25 p.m., the DON stated the facility did not document or monitor resident's intake and output unless there was a physician's orders [REDACTED]." Review of the facility's 24 Hour Reports dated 04/24/14 through 05/05/14 revealed no documentation regarding R #1's hydration status. On 05/09/14 at 9:15 a.m., LVN "Z" stated it was not the facility's policy to monitor a resident's intake and output and staff "haven't done it." LVN "Z" stated, "I feel it's important to monitor (intake and output). A resident could get confused, a resident could die because of dehydration [MEDICAL CONDITION]." Surveyor asked LVN "Z" how she would know a resident was at risk for dehydration. LVN "Z" stated, "I don't know how I would know." LVN "Z" stated she would assess for dehydration by "dry skin, low output, mental status" and "would put it in the nurses notes. It should at least be charted every shift when there is a problem." On 05/09/14 at 9:40 a.m., LVN "A" stated a resident who was at risk for dehydration should be assessed for "change in status, sunken eyes, skin turgor" and there "should be charting to know if (a resident was) assessed for dehydration." R #3 R #3's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]., Cerebral Vascular Disease, Basal Ganglia Degeneration ([MEDICAL CONDITION] that fails to suppress unwanted movements), Paralytic Ileus (intestinal paralysis), Intestinal Obstruction, Tracheotomy, [MEDICAL CONDITION], Constipation, Dementia, Vascular Urinary Obstruction, Diarrhea and [MEDICAL CONDITION]. R #3's Quarterly MDS dated [DATE] revealed R #3 was unable to speak, rarely/never understood others nor was understood by others, had long and short term memory problems, was totally dependent with all ADLs and required the assistance of two persons with dressing and transfers, was incontinent of urine and had an [MEDICAL CONDITION] for bowel movements, tube feeding; received 51% or more nutrition through a [DEVICE] feedings; and received 501 cc/day or more fluid intake through a feeding tube, received oxygen therapy, tracheotomy care and suctioning. R #3's Nursing Assistant Care Plan dated 11/12/13 "Nutritional Status" revealed R #3 had a "tube feeder" and was incontinent of urine and had a [MEDICAL CONDITION]. R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed R #3: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 2:00 p.m.-10:00 p.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed an additional [DIAGNOSES REDACTED]." R #3's Care Plans dated 03/17/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T Dysphagia and [DEVICE] use .....Goal: Residents Nutritional Status will be maintained, Resident will have measures to decrease the potential of ...Dehydration ... Approach: Monitor for Signs and Symptoms of Dehydration, Dry Mucus Membranes, Decreased Output, changes in LOC, Change in Lab Values ..... ...Potential For Impaired Urinary Flow D/T HX. Urethral Obstruction ... Goal ...Resident Will Not Experience any Obstruction of Urinary Flow By Next Review ...Approach ...Monitor For Adequate Urinary Output Lower ABD Distention or Discomfort." R #3's Nurses Notes dated 03/20/14 through 05/08/14 revealed no documentation reflecting R #3 was assessed for Dehydration or Urinary Output. R #3's Nutritional Progress Note dated 03/28/14 revealed R #3 was NPO (nothing by mouth) and received [DEVICE] feedings with "[MEDICATION NAME]" (liquid nutrition) at 40 cc/hr for 22 hours and flushed with 340 cc of water every four hours. R #3's Monthly Summary dated 04/21/14 revealed: "Eating ...Total Dependence Why is this support needed: Tube Feeding due to volume depletion, dehydration, [MEDICAL CONDITION]." R #3's Laboratory Report dated 04/17/14 revealed: -Urea Nitrogen-29 H Reference range (7-25) -Creatinine-1.4 H Reference range (0.7-1.3). -eGFR-49 L Reference range (90>) The Laboratory Report dated 04/17/14 indicated R #3 had the potential to be dehydrated. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE], with the following Diagnoses: [REDACTED]. R #4's MDS dated [DATE] revealed R #4 was rarely/never understood by others nor understood others; cognitive skills for daily decision making were severely impaired-never/rarely made decisions; had total dependence with bed mobility and transfers and required two person assist; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; received 501 cc/day or more fluid intake through a [DEVICE]; had two stage two Pressure Ulcers; and medication included a diuretic. R #4's Nursing Assistant Care Plan dated 11/11/13 revealed: -"Nutritional Status" section revealed R #4 had [DEVICE] and was NPO, -"Elimination-Bladder, Elimination- Bowel" section revealed R #4 was incontinent of urine and bowel, -"Diet" section revealed R #4 had [MEDICAL CONDITION] feeding @35cc/hr. Flush with water per M.D. Orders. R #4's ADL Flow Sheet dated 05/01/14 through 05/31/14 revealed R #4: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 10:00 pm.-6:00 a.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #4's Care Plan dated 03/11/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T [DEVICE] Fed, NPO, and Dependent on Others for Nutrition and Hydration. .....Goal: Resident will have Measures to maintain Nutritional Status, be well Hydrated... Approach: Monitor for Dry Mucus Membranes, Fever, Poor Skin Turgor, Change in LOC, Changes in Lab Values." R #4's Care Plan entitled "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "-Goal: Consume Adequate Fluids -Approaches: Monitor s/s of dehydration, poor skin turgor, dry mucus membranes, offer fluids per GT, Monitor for [MEDICAL CONDITION]/dyspnea, Labs as ordered, Educate resident and/or family." R #4's Nurses Notes dated 11/05/13 through 05/06/14 revealed no documentation reflecting R #4 was assessed for Dehydration or Urinary Output. R #4's Consolidated Physician order [REDACTED]. R #4 had an order for [REDACTED]. Flush GT with 150cc of water every four hours. According to Mosby's 25th Edition: Nursing Drug Reference; [MEDICATION NAME] had the following precautions:...."dehydration." R #9 R #9's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. R #9's consolidated Physician order [REDACTED]. Once a day on the 15th of the month; 11:00 p.m.-7:00 a.m." R #9's Admission Care Plan dated 12/31/13 revealed; "Dehydration/Fluid Maintenance - Goal: Resident will consume adequate fluids..... - Monitor for signs/symptoms of dehydration... - Laboratory work as ordered... UTI FC (Urinary tract Infection/Urinary Catheter) - Goal: Resolve -Monitor every shift for UTI symptoms - Intake and Output." R #9's Laboratory Report dated 01/08/14 revealed: -Chloride-108 H (high) Reference range (98-107) previous results 08/24/13-101, -Urea Nitrogen-33 H Reference range (7-25) previous results 8/24/13-16, -Creatinine-1.5 H Reference range (0.7-1.3) previous results 8/24/13-1.1, -Osmolarity-293 H Reference range (260-278) previous results 8/24/13-277, -eGFR-44 L (low) Reference range (90>) (greater than 90) previous results 8/24/13-63. The Laboratory Report dated 01/08/14 indicated R #1 had the potential to be dehydrated. R #9's Care Plans dated 01/10/14 revealed there were no care plans specific to monitoring Intake and Output or Dehydration. R #9's Quarterly MDS dated [DATE] revealed R #9 had difficulty hearing, was sometimes understood and sometimes understood others, vision was moderately impaired,had both short and long term memory problems, cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required, required the assistance of two persons for transfers, required set up for meals, had an indwelling urinary catheter and a [MEDICAL CONDITION], and two unstageable decubitus ulcers. R #9's undated Nursing Assistant Care Plan regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan, but there was no specific care provision documented. R #9's Nursing Assistant Care Plan dated 05/01/14 regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan with specific instruction "I&O's Q shift." R #9's undated Summary/Registered Dietician Recommendations estimated fluid intake was 2000-2400 cc of fluids per day. R #9's medical record did not have any documentation revealing amount of fluid intake. R #9's ADL Flow Sheets revealed: 04/01/14-04/30/14: -There was no documentation for the entire month, on the 6:00 a.m.-2:00 p.m. shift for urine output measurement. - 04/06/14 through 04/08/14, there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. - 04/14/14 and 04/16/14 there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. Dated 05/01/14-05/31/14: -There was no documentation 05/01/14-05/06/14, on the 6:00 a.m.-2:00 p.m. or the 2:00 p.m.-10:00 p.m. shift. for urine output measurement. - 05/02/14 total documented urine output was 400 (no units of measurements noted). - 05/16/14 total urine output documented was 500. (no units of measurements noted). - 05/07/14 and 05/30/14 there was 600 total urine output documented.(no units of measurements noted). According to Lippincott's Nursing Procedures, 6th Edition, pages 376 and 377: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." On 05/09/14 at 9:30 a.m., LVN "M" said the policy of the facility was to monitor Intake and Output on residents with indwelling urinary catheters because of complications related to indwelling catheters such as obstruction, infection or dislodgement. The CNAs emptied the urinary catheter bags at the end of the shift and documented the output amount on the ADL sheet. The LVN "M" said, if the Output was not documented on the ADL sheet then the nurses would not be able to track how much out put that resident had for the shift. LVN "M" said, "if a resident were to become dehydrated or septic they would become delirious, get really sick and die and that (LVN "M") has seen a resident at the facility, become dehydrated in the past." LVN "M" said, "hydration was of top priority because people need fluids to stay alive." On 05/09/14 at 9:55 a.m., CNA "L" said that prior to yesterday the staff never had any formal training at the facility in measuring Intakes and Outputs for residents with urinary catheters. The CNA's knew what care to provide each resident by following the Nursing Assistant Care Plan. On 05/09/14 at 10:10 a.m., CNA "K" said, the CNA's were supposed to encourage residents to drink fluids. The CNAs were to empty out urinary catheter bags every shift and document on the resident's individual ADL sheet how much the resident urinated for that shift. If a resident became dehydrated, that could lead to constipation. On 05/09/14 at 1030 a.m., LVN "P" said the nurses were supposed to document in the nurses notes, and on the Intake and Output book all Intake and Outputs on residents with urinary catheters and residents that received [DEVICE] feedings. Residents at risk for dehydration were residents with dementia, [MEDICAL TREATMENT], thickened liquids. For Residents without urinary catheters the staff measured the Output by how many times the diaper had been changed, and if diaper was wet or soaked. The CNAs were to report any change in resident urination pattern, dark colored urine or foul odor to the nurse. The CNAs also emptied the urine bags every shift and documented the amount of output in the ADL sheet. If the CNAs were to not document how much out put the resident had at the end of the shift there would not be anyway for the nurses to know if the resident had voided. If a resident doesn't have adequate hydration they could become dehydrated and eventually expire. On 05/09/14 at 10:50 a.m., CNA"N"said, staff were in-serviced yesterday on how to determine if a resident was dehydrated. CNA"N"said, if a resident was dehydrated, the resident would be confused, not urinate and have poor skin elasticity. Residents with urinary catheters, the CNAs were supposed to write down the urine output every shift in the ADL book. The nurses and the aides would keep track of how much fluid the residents consumed by observing the meal trays to track how much the resident drank and encourage fluid intake. The CNAs knew what care to provide each resident by following the Nursing Assistant Care Plan. R #10 R #10's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #10's Quarterly MDS dated [DATE] revealed R #10 usually understood others and made self understood; had inattention and disorganized thinking; was independent with eating; was always continent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #10's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor for s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids - To nectar consistency. Resident has [DEVICE] (with) feeding @ HS...Monitor for [MEDICAL CONDITION]/dyspnea (swelling/air hunger..." R #10's Physician order [REDACTED]. -Regular diet with nectar thick liquids, -Offer 6-8 ounces of water thickened to nectar consistency four times a day with med pass, -Flush [DEVICE] with 150cc water every four hours, -Per [DEVICE]: "[MEDICATION NAME] 1.5 Cal (liquid nutrition) to infuse at 75cc/hr via pump x 10 hrs/day (8pm-6am) to provide...570cc free H2O..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." R #10's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #10's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #10's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #10's Nurses Notes revealed: -Dated 04/08/14 through 04/17/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. -There was no documentation from 04/17/14 through 04/23/14, approximately six days. -There was no documentation from 04/24/14 through 04/28/14, approximately four days. -There was no documentation from 04/29/14 through 05/02/14, approximately four days. -Dated 05/03/14 through 05/08/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. R #11 R #11's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #11's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor s/s of dehydration (poor skin turgor, dry mucous membranes,) Offer Fluids - To nectar consistency. Resident also receives feedings per [DEVICE]...Monitor for [MEDICAL CONDITION]/dyspnea..." R #11's Annual MDS dated [DATE] revealed R #11 sometimes understood others and sometimes made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); had inattention and disorganized thinking; was totally dependent on staff for eating; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #11's Physician order [REDACTED]. -"Offer 6-8 oz H2O thickened to nectar consistency QID with med pass" -Pureed diet, thicken liquids to nectar consistency -Per [DEVICE]: "[MEDICATION NAME] 1.5 (liquid nutrition) to infuse at 55cc/hr x 22 hrs/day total provided...919cc free H2O q shift..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -"Flush tube with 150cc H2O q4h..." R #11's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #11's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #11's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #11's Nurses Notes revealed: -Dated 04/21/14 through 04/24/14 revealed there was no documentation R #11 was assessed for poor skin turgor or dry mucous membranes. -Dated 04

Based on observation, interview and record review the facility failed to implement their written policy and procedure that prohibits neglect for six Residents (R #1, R #3, R #4, R #9, R #10, R #11) of 16 Residents reviewed for hydration and infections. R #1 had a recent hospitalization with a [DIAGNOSES REDACTED].#1's condition. As a result of this, R #1 was sent to the hospital [MEDICAL CONDITION], dehydration and pus in his urine. R #1 was discharged to another facility from the hospital with hospice. The facility was aware that R #3, R #4, R #9, R #10 and R #11 were at risk for dehydration and did not consistently monitor and document those residents' conditions. These failures resulted in identification of an Immediate Jeopardy (IJ) on 05/08/14 at 10:50 a.m. While the IJ was removed on 05/09/14 at 12:15 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed 16 residents with [DEVICE]s, seven residents with indwelling urinary catheters and 123 residents with hydration issues at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: The facility's Abuse Policy dated 01/2008, revised date 11/2013 revealed: "POLICY It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person...DEFINITIONS...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." The facility's Dietary Services Policy and Procedure dated 11/2008 entitled "Hydration", revised dates 7/2009, 10/2010 and 6/2013 revealed: "...APPLIES TO Dietary/Nursing...PURPOSE It is the policy of this home that the facility will provide hydration for all residents as determined by the Consultant Dietitian's assessment of the resident's needs. All efforts will be made to prevent dehydration. PROCEDURE ...2. The resident will have their hydration status assessed by the MDS evaluation. The following areas will be reviewed to determine their risk for dehydration: a. indicators of [MEDICAL CONDITION] b. moderate/severe impaired decision making ability c. comprehension/communication problems d. body control problems e. hand dexterity problems f. constipation (or history of) g. history of fecal impaction h. swallowing problems i. recent deterioration in ADL's (from observation and from direct care staff) j. temperature or infection k. vomiting and/or diarrhea 3. The Inter-Disciplinary Care Plan Team will identify risk factors which could place the resident at risk for dehydration and will develop, implement and modify the plan of care to manage the resident's hydration status. The following are risk factors associated with dehydration: a. Coma/decreased sensory status b. Fluid loss c. Increased fluid needs (ex. Diarrhea, vomiting, fever, uncontrolled diabetes) d. Impairments, which make assessing, drinking, and communicating the need for fluids difficult e. Dementia f. Refusal to drink/poor appetite 4. The facility will observe the resident for signs and symptoms of dehydration: a. Dry skin and mucus membranes, b. Poor skin turgor, c. Cracked lips, d. Thirst, e. Fever, and f. Abnormal labs: hemoglobin, hematocrit, potassium, chloride, BUN, Creatinine and urine specific gravity. 5. The staff will notify the physician and resident's representative if a resident is identified as showing signs and symptoms of dehydration and change orders as needed..." The facility's Nursing Policy and Procedure dated 01/2008 entitled "Intake and Output Measurement", revised date 01/20/14 revealed: "POLICY It is the policy of this home to provide accurate measurement of intake and output when ordered by the Physician and/or when it is determined to be necessary to meet the resident's needs. EQUIPMENT 1. (Intake and Output Record)... The Nurse may at his/her Discretion Initiate Measurement And Documentation Of Intake And Output Every Eight Hours, Including A 24-Hour Total And Evaluation: 1. Some conditions that may warrant the decision may include, but is not limited to: ? Diuresis (increased urine output) ? Hydration ? Change of condition PROCEDURE 1. All fluids consumed during each 24 hour period Intake and Output will be measured and recorded in cubic centimeters (ml) will be measured and documented on the (Intake and Output Record Form) 2. Total the Intake and Output from the Input and Output Record at the end of each shift and record the total intake and output measurement on the individual (Intake and Output Worksheet Form). 3. Fluids taken enterally or intravenously will be recorded by the licensed nurse. 4. Output is any fluid lost by the resident to include urine, emesis, diarrhea stool and blood 5. Intake and Output will be totaled from the three shifts and recorded at the end of each 24 hours on the resident's individual Intake and Output record" The facility's "Enteral Formula Via: Feeding Tube, Bolus, Gravity, Pump (Closed/Open) Administration" Policy dated 01/2008, revised date 03/2012 revealed: "POLICY It is the policy of this home that the resident, who utilizes enteral nutrition, will be free, to the extent possible, from complications related to enteral nutrition..." R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to Facility "DD" on 01/23/13 with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 had no speech; rarely/never made self understood; sometimes understood others; had a moderately impaired cognition (decisions poor; cues/supervision required); was totally dependent on staff for eating, toilet use, bed mobility, locomotion, personal hygiene and bathing; was always incontinent of bowel and bladder; was not dehydrated; received oxygen therapy; had a feeding tube; received 51% or more nutrition through a feeding tube; and received 501 cc/day or more fluid intake through a feeding tube. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Dehydration/Fluid Maintenance. R #1's Care Plan dated 02/28/14 revealed: -"Care Plan for Residents with risks for Dehydration...Monitor s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids [DEVICE] as ordered..." R #1's Consolidated Physician order [REDACTED]. -03/13/14: "[MEDICATION NAME] (liquid nutrition via [DEVICE]) to infuse at 55cc/hr x 22hrs/day...to provide...949cc free H2O..." -04/09/13: "Flush [DEVICE] with 180cc H2O q4h..." -11/14/13: "Flush [DEVICE] with a least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -Magnesium oxide (supplement) 400mg TID. SE: electrolyte, fluid imbalances. -[MEDICATION NAME] (anticonvulsant) 250mg=10mL TID. SE: [MEDICAL CONDITION] (inflammation of the kidneys.) -Trazadone (antidepressant) 25mg BID. SE: Acute [MEDICAL CONDITION]. According to Lippincott's 2013 Nursing Procedures, Sixth Edition, page 729, documentation for gastrostomy tube feeding and complications included: -"On the intake and output record (I&O), note the date, time, and amount of each feeding and the water volume instilled..." -"Maintain total volumes for nutrients and water separately to allow calculation of nutrient intake..." -"In your notes, document the type of formula, the infusion method and rate, the patient's tolerance of the procedure and formula, and the amount of residual gastric contents..." -"...complications include...fluid and electrolyte imbalances..." R #1's "Enteral Flowsheets", "Enteral Meds Flowsheets", and "Medications Flowsheets" dated 04/2014 and 05/2014 revealed no documentation of R #1's total intake of tube feeding formula and water volumes instilled. R #1's ADL Flowsheets dated 04/2014 and 05/2014 revealed R #1 was "wet" three times on each shift: 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. The ADL Flowsheets did not describe what "wet" represented. R #1's Nurses Notes revealed the following entries dated 04/01/14: -1:30 a.m.: "Found resident responsed (sic) not like used to. Check v/s (BP) 72/48, (T) 97.3, (P) 80, (R) 22...Called (physician)..." -1:55 a.m.: "...Resident is transferred to (Hospital "AA")..." -5:00 a.m.: "Resident came back from (Hospital "AA")...(with) new ordered (antibiotic)...still not response (sic) well this time..." R #1's Discharge Summary dated 04/01/14 from Hospital "AA" revealed R #1's [DIAGNOSES REDACTED]. R #1's Nurses Notes and Monthly Summary revealed the following: Nurses Notes: -From 04/13/14 at 5:00 p.m. through 04/17/14 at 2:00 p.m. revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 3 days and 21 hours. -From 04/20/14 at 6:00 p.m. through 04/26/14 until 10:00 a.m. revealed no documentation of R #1's condition, approximately 5 days and 16 hours. -From 04/29/14 at 2:23 p.m. through 05/05/14 until 2:30 a.m. revealed no documentation of R #1's condition, approximately 5 days and 12 hours. -05/05/14 at 2:30 a.m.: "Upon entering room, found resident'[MEDICAL CONDITION] large amount of coffee brown emesis (with) phlegm. Suction given @ this time. 02 sat 81% @ 3 LPM...Check v/s (T) 100.9, (BP) 100/67, (P) 91, (R) 24. Tylenol 650mg gave @ this time..." -2:45 a.m.: The physician was called regarding R #1's condition. -3:10 a.m.: "Call 911 to transfer resident to (Hospital "AA")..." -3:15 a.m.: "911 staff here to transfer resident to (Hospital "AA")..." Monthly Summary dated 05/01/14: -"Dry Skin" and "Mucous Membrane Moist." According to the American Medical Directors Association, www.amda.com, retrieved on 05/16/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Provider Report dated 05/05/14 from Hospital "AA" revealed: -3:49 a.m.: BP 89/65, P 85, R 16, T 99.3 -3:51 a.m.: "...lethargic, dehydrated..." -7:11 a.m.: BP 77/53, P 73, R 20, T 100.4 at 6:00 a.m. R #1's History and Physical dated 05/05/14 from Hospital "AA" revealed R #1 was diagnosed with [REDACTED]. R #1's Clinical Note dated 05/05/14 from Hospital "AA" revealed: -12:34 p.m.: "...After insertion of the (indwelling catheter) 300cc of purulent (pus) urine was returned..." -7:28 p.m.: "...Pt was admitted to ICU..." According to www.sepsisalliance.org on 05/12/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 05/12/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's Laboratory Test results dated 05/05/14 from Hospital "AA" revealed: Urinalysis: -"Urine appearance HAZY" Normal range "CLEAR." -"Urine pH 8.0 H" Normal range 5.5-7.0. -"Urine Protein 25 H" Normal range "NEGATIVE." -"Urine Blood 1+ H" Normal range "NEGATIVE." -"Urine [MEDICATION NAME] POSITIVE H" Normal range "NEGATIVE." -"(Urine) Leukocyte Esterase 2+ H" Normal range "NEGATIVE." -"Urine WBC 5-10 H" Normal range "NONE SEEN." -"(Urine) Transition Epith Cell FEW H" Normal range "NONE SEEN." -"Urine Bacteria 1+" Normal range "NONE SEEN." The Urinalysis dated 05/05/14 indicated R #1 had the potential to have a urinary tract infection. Blood Chemistry: -"BUN 21 H" Normal range 6-20. -"Glucose 135 H" Normal range 65-99. The Blood Chemistry dated 05/05/14 indicated R #1 had the potential to be dehydrated. R #1's Hospitalist Progress Note dated 05/06/14 from Hospital "AA" revealed: -24 hour total intake was 2085cc and total output was 855cc. -"...prognosis is very poor for this patient..." Observation on 05/07/14 at 10:20 a.m., at Hospital "AA", revealed R #1 lying in bed in ICU and unresponsive to surveyor's questions. On 05/07/14 at 10:25 a.m., MD "CC" from Hospital "AA" stated R #1 was "dehydrated" when admitted to the hospital on [DATE] and "[MEDICAL CONDITION] criteria." MD "CC" stated R #1's prognosis was "poor." On 05/08/14 at 11:00 a.m., SW "BB" from Hospital "AA" stated R #1 was discharged to another facility with hospice. The following information was gathered at Facility "DD": On 05/08/14 at 8:00 a.m., LVN "V" stated it was not the facility's policy to document or monitor a resident's intake and output, except for "fluid restriction." LVN "V" stated a resident's skin turgor and vital signs should be monitored to assess for dehydration and that if something was not "written down (in the nurses notes), it didn't happen." Surveyor asked LVN "V" how he would know a resident was at risk for dehydration. LVN "V" stated he would know by a resident's diagnosis. On 05/08/14 at 8:25 a.m., CNA "W" stated it was not the facility's policy to document or monitor a resident's intake and output. CNA "W" stated monitoring intake and output "should be done for residents" who were at risk for dehydration because a resident "could get dehydrated, decline in health, (and) organs won't work correctly." CNA "W" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "W" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:10 a.m., CNA "Y" stated it was not the facility's policy to document or monitor a resident's intake and output. Surveyor asked CNA "Y" how she would know a resident was at risk for dehydration. CNA "Y" stated a resident's ADL Flowsheet would alert staff that a resident was at risk for dehydration if the resident had "nectar liquids." CNA "Y" stated a resident who was dehydrated could get a "UTI" and "go to the hospital." CNA "Y" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "Y" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:25 a.m., CNA "X" stated residents who were at risk for dehydration were "monitored by the nurses." On 05/08/14 at 9:55 a.m., the DON stated nurses would know a resident was at risk for dehydration if the resident had "been in the hospital," nurses would "look at the whole picture," document the resident's condition on the "24 Hour Report" and do a "head to toe assessment." The DON stated the CNAs would know a resident was at risk for dehydration by looking at the "Care Plan" and "from the nurses." The DON stated, "It's a nursing thing to know if a resident is at risk for dehydration. We will monitor the resident." Surveyor asked the DON how staff monitored residents at risk for dehydration. The DON stated, "It depends on the resident. Nurses make rounds to monitor residents for dehydration...All residents are at risk for dehydration or they wouldn't be here." On 05/07/14 at 12:25 p.m., the DON stated the facility did not document or monitor resident's intake and output unless there was a physician's orders [REDACTED]." Review of the facility's 24 Hour Reports dated 04/24/14 through 05/05/14 revealed no documentation regarding R #1's hydration status. On 05/09/14 at 9:15 a.m., LVN "Z" stated it was not the facility's policy to monitor a resident's intake and output and staff "haven't done it." LVN "Z" stated, "I feel it's important to monitor (intake and output). A resident could get confused, a resident could die because of dehydration [MEDICAL CONDITION]." Surveyor asked LVN "Z" how she would know a resident was at risk for dehydration. LVN "Z" stated, "I don't know how I would know." LVN "Z" stated she would assess for dehydration by "dry skin, low output, mental status" and "would put it in the nurses notes. It should at least be charted every shift when there is a problem." On 05/09/14 at 9:40 a.m., LVN "A" stated a resident who was at risk for dehydration should be assessed for "change in status, sunken eyes, skin turgor" and there "should be charting to know if (a resident was) assessed for dehydration." R #3 R #3's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]., Cerebral Vascular Disease, Basal Ganglia Degeneration ([MEDICAL CONDITION] that fails to suppress unwanted movements), Paralytic Ileus (intestinal paralysis), Intestinal Obstruction, Tracheotomy, [MEDICAL CONDITION], Constipation, Dementia, Vascular Urinary Obstruction, Diarrhea and [MEDICAL CONDITION]. R #3's Quarterly MDS dated [DATE] revealed R #3 was unable to speak, rarely/never understood others nor was understood by others, had long and short term memory problems, was totally dependent with all ADLs and required the assistance of two persons with dressing and transfers, was incontinent of urine and had an [MEDICAL CONDITION] for bowel movements, tube feeding; received 51% or more nutrition through a [DEVICE] feedings; and received 501 cc/day or more fluid intake through a feeding tube, received oxygen therapy, tracheotomy care and suctioning. R #3's Nursing Assistant Care Plan dated 11/12/13 "Nutritional Status" revealed R #3 had a "tube feeder" and was incontinent of urine and had a [MEDICAL CONDITION]. R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed R #3: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 2:00 p.m.-10:00 p.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed an additional [DIAGNOSES REDACTED]." R #3's Care Plans dated 03/17/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T Dysphagia and [DEVICE] use .....Goal: Residents Nutritional Status will be maintained, Resident will have measures to decrease the potential of ...Dehydration ... Approach: Monitor for Signs and Symptoms of Dehydration, Dry Mucus Membranes, Decreased Output, changes in LOC, Change in Lab Values ..... ...Potential For Impaired Urinary Flow D/T HX. Urethral Obstruction ... Goal ...Resident Will Not Experience any Obstruction of Urinary Flow By Next Review ...Approach ...Monitor For Adequate Urinary Output Lower ABD Distention or Discomfort." R #3's Nurses Notes dated 03/20/14 through 05/08/14 revealed no documentation reflecting R #3 was assessed for Dehydration or Urinary Output. R #3's Nutritional Progress Note dated 03/28/14 revealed R #3 was NPO (nothing by mouth) and received [DEVICE] feedings with "[MEDICATION NAME]" (liquid nutrition) at 40 cc/hr for 22 hours and flushed with 340 cc of water every four hours. R #3's Monthly Summary dated 04/21/14 revealed: "Eating ...Total Dependence Why is this support needed: Tube Feeding due to volume depletion, dehydration, [MEDICAL CONDITION]." R #3's Laboratory Report dated 04/17/14 revealed: -Urea Nitrogen-29 H Reference range (7-25) -Creatinine-1.4 H Reference range (0.7-1.3). -eGFR-49 L Reference range (90>) The Laboratory Report dated 04/17/14 indicated R #3 had the potential to be dehydrated. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE], with the following Diagnoses: [REDACTED]. R #4's MDS dated [DATE] revealed R #4 was rarely/never understood by others nor understood others; cognitive skills for daily decision making were severely impaired-never/rarely made decisions; had total dependence with bed mobility and transfers and required two person assist; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; received 501 cc/day or more fluid intake through a [DEVICE]; had two stage two Pressure Ulcers; and medication included a diuretic. R #4's Nursing Assistant Care Plan dated 11/11/13 revealed: -"Nutritional Status" section revealed R #4 had [DEVICE] and was NPO, -"Elimination-Bladder, Elimination- Bowel" section revealed R #4 was incontinent of urine and bowel, -"Diet" section revealed R #4 had [MEDICAL CONDITION] feeding @35cc/hr. Flush with water per M.D. Orders. R #4's ADL Flow Sheet dated 05/01/14 through 05/31/14 revealed R #4: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 10:00 pm.-6:00 a.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #4's Care Plan dated 03/11/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T [DEVICE] Fed, NPO, and Dependent on Others for Nutrition and Hydration. .....Goal: Resident will have Measures to maintain Nutritional Status, be well Hydrated... Approach: Monitor for Dry Mucus Membranes, Fever, Poor Skin Turgor, Change in LOC, Changes in Lab Values." R #4's Care Plan entitled "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "-Goal: Consume Adequate Fluids -Approaches: Monitor s/s of dehydration, poor skin turgor, dry mucus membranes, offer fluids per GT, Monitor for [MEDICAL CONDITION]/dyspnea, Labs as ordered, Educate resident and/or family." R #4's Nurses Notes dated 11/05/13 through 05/06/14 revealed no documentation reflecting R #4 was assessed for Dehydration or Urinary Output. R #4's Consolidated Physician order [REDACTED]. R #4 had an order for [REDACTED]. Flush GT with 150cc of water every four hours. According to Mosby's 25th Edition: Nursing Drug Reference; [MEDICATION NAME] had the following precautions:...."dehydration." R #9 R #9's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. R #9's consolidated Physician order [REDACTED]. Once a day on the 15th of the month; 11:00 p.m.-7:00 a.m." R #9's Admission Care Plan dated 12/31/13 revealed; "Dehydration/Fluid Maintenance - Goal: Resident will consume adequate fluids..... - Monitor for signs/symptoms of dehydration... - Laboratory work as ordered... UTI FC (Urinary tract Infection/Urinary Catheter) - Goal: Resolve -Monitor every shift for UTI symptoms - Intake and Output." R #9's Laboratory Report dated 01/08/14 revealed: -Chloride-108 H (high) Reference range (98-107) previous results 08/24/13-101, -Urea Nitrogen-33 H Reference range (7-25) previous results 8/24/13-16, -Creatinine-1.5 H Reference range (0.7-1.3) previous results 8/24/13-1.1, -Osmolarity-293 H Reference range (260-278) previous results 8/24/13-277, -eGFR-44 L (low) Reference range (90>) (greater than 90) previous results 8/24/13-63. The Laboratory Report dated 01/08/14 indicated R #1 had the potential to be dehydrated. R #9's Care Plans dated 01/10/14 revealed there were no care plans specific to monitoring Intake and Output or Dehydration. R #9's Quarterly MDS dated [DATE] revealed R #9 had difficulty hearing, was sometimes understood and sometimes understood others, vision was moderately impaired,had both short and long term memory problems, cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required, required the assistance of two persons for transfers, required set up for meals, had an indwelling urinary catheter and a [MEDICAL CONDITION], and two unstageable decubitus ulcers. R #9's undated Nursing Assistant Care Plan regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan, but there was no specific care provision documented. R #9's Nursing Assistant Care Plan dated 05/01/14 regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan with specific instruction "I&O's Q shift." R #9's undated Summary/Registered Dietician Recommendations estimated fluid intake was 2000-2400 cc of fluids per day. R #9's medical record did not have any documentation revealing amount of fluid intake. R #9's ADL Flow Sheets revealed: 04/01/14-04/30/14: -There was no documentation for the entire month, on the 6:00 a.m.-2:00 p.m. shift for urine output measurement. - 04/06/14 through 04/08/14, there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. - 04/14/14 and 04/16/14 there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. Dated 05/01/14-05/31/14: -There was no documentation 05/01/14-05/06/14, on the 6:00 a.m.-2:00 p.m. or the 2:00 p.m.-10:00 p.m. shift. for urine output measurement. - 05/02/14 total documented urine output was 400 (no units of measurements noted). - 05/16/14 total urine output documented was 500. (no units of measurements noted). - 05/07/14 and 05/30/14 there was 600 total urine output documented.(no units of measurements noted). According to Lippincott's Nursing Procedures, 6th Edition, pages 376 and 377: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." On 05/09/14 at 9:30 a.m., LVN "M" said the policy of the facility was to monitor Intake and Output on residents with indwelling urinary catheters because of complications related to indwelling catheters such as obstruction, infection or dislodgement. The CNAs emptied the urinary catheter bags at the end of the shift and documented the output amount on the ADL sheet. The LVN "M" said, if the Output was not documented on the ADL sheet then the nurses would not be able to track how much out put that resident had for the shift. LVN "M" said, "if a resident were to become dehydrated or septic they would become delirious, get really sick and die and that (LVN "M") has seen a resident at the facility, become dehydrated in the past." LVN "M" said, "hydration was of top priority because people need fluids to stay alive." On 05/09/14 at 9:55 a.m., CNA "L" said that prior to yesterday the staff never had any formal training at the facility in measuring Intakes and Outputs for residents with urinary catheters. The CNA's knew what care to provide each resident by following the Nursing Assistant Care Plan. On 05/09/14 at 10:10 a.m., CNA "K" said, the CNA's were supposed to encourage residents to drink fluids. The CNAs were to empty out urinary catheter bags every shift and document on the resident's individual ADL sheet how much the resident urinated for that shift. If a resident became dehydrated, that could lead to constipation. On 05/09/14 at 1030 a.m., LVN "P" said the nurses were supposed to document in the nurses notes, and on the Intake and Output book all Intake and Outputs on residents with urinary catheters and residents that received [DEVICE] feedings. Residents at risk for dehydration were residents with dementia, [MEDICAL TREATMENT], thickened liquids. For Residents without urinary catheters the staff measured the Output by how many times the diaper had been changed, and if diaper was wet or soaked. The CNAs were to report any change in resident urination pattern, dark colored urine or foul odor to the nurse. The CNAs also emptied the urine bags every shift and documented the amount of output in the ADL sheet. If the CNAs were to not document how much out put the resident had at the end of the shift there would not be anyway for the nurses to know if the resident had voided. If a resident doesn't have adequate hydration they could become dehydrated and eventually expire. On 05/09/14 at 10:50 a.m., CNA"N"said, staff were in-serviced yesterday on how to determine if a resident was dehydrated. CNA"N"said, if a resident was dehydrated, the resident would be confused, not urinate and have poor skin elasticity. Residents with urinary catheters, the CNAs were supposed to write down the urine output every shift in the ADL book. The nurses and the aides would keep track of how much fluid the residents consumed by observing the meal trays to track how much the resident drank and encourage fluid intake. The CNAs knew what care to provide each resident by following the Nursing Assistant Care Plan. R #10 R #10's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #10's Quarterly MDS dated [DATE] revealed R #10 usually understood others and made self understood; had inattention and disorganized thinking; was independent with eating; was always continent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #10's "Care Plan f

Based on observation, interview and record review the facility failed to provide services in accordance with each resident's written plan of care for six Residents (R #1, R #3, R #4, R #9, R #10, R #11) of 16 Residents reviewed for hydration and infections. R #1 had a recent hospitalization with a [DIAGNOSES REDACTED].#1's condition. As a result of this, R #1 was sent to the hospital [MEDICAL CONDITION], dehydration and pus in his urine. R #1 was discharged to another facility from the hospital with hospice. The facility was aware that R #3, R #4, R #9, R #10 and R #11 were at risk for dehydration and did not consistently monitor and document those residents' conditions. These failures resulted in identification of an Immediate Jeopardy (IJ) on 05/08/14 at 10:50 a.m. While the IJ was removed on 05/09/14 at 12:15 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed 16 residents with [DEVICE]s, seven residents with indwelling urinary catheters and 123 residents with hydration issues at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to Facility "DD" on 01/23/13 with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 had no speech; rarely/never made self understood; sometimes understood others; had a moderately impaired cognition (decisions poor; cues/supervision required); was totally dependent on staff for eating, toilet use, bed mobility, locomotion, personal hygiene and bathing; was always incontinent of bowel and bladder; was not dehydrated; received oxygen therapy; had a feeding tube; received 51% or more nutrition through a feeding tube; and received 501 cc/day or more fluid intake through a feeding tube. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Dehydration/Fluid Maintenance. R #1's Care Plan dated 02/28/14 revealed: -"Care Plan for Residents with risks for Dehydration...Monitor s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids [DEVICE] as ordered..." R #1's Consolidated Physician order [REDACTED]. -03/13/14: "[MEDICATION NAME] (liquid nutrition via [DEVICE]) to infuse at 55cc/hr x 22hrs/day...to provide...949cc free H2O..." -04/09/13: "Flush [DEVICE] with 180cc H2O q4h..." -11/14/13: "Flush [DEVICE] with a least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -Magnesium oxide (supplement) 400mg TID. SE: electrolyte, fluid imbalances. -[MEDICATION NAME] (anticonvulsant) 250mg=10mL TID. SE: [MEDICAL CONDITION] (inflammation of the kidneys.) -Trazadone (antidepressant) 25mg BID. SE: Acute [MEDICAL CONDITION]. According to Lippincott's 2013 Nursing Procedures, Sixth Edition, page 729, documentation for gastrostomy tube feeding and complications included: -"On the intake and output record (I&O), note the date, time, and amount of each feeding and the water volume instilled..." -"Maintain total volumes for nutrients and water separately to allow calculation of nutrient intake..." -"In your notes, document the type of formula, the infusion method and rate, the patient's tolerance of the procedure and formula, and the amount of residual gastric contents..." -"...complications include...fluid and electrolyte imbalances..." R #1's "Enteral Flowsheets", "Enteral Meds Flowsheets", and "Medications Flowsheets" dated 04/2014 and 05/2014 revealed no documentation of R #1's total intake of tube feeding formula and water volumes instilled. R #1's ADL Flowsheets dated 04/2014 and 05/2014 revealed R #1 was "wet" three times on each shift: 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. The ADL Flowsheets did not describe what "wet" represented. R #1's Nurses Notes revealed the following entries dated 04/01/14: -1:30 a.m.: "Found resident responsed (sic) not like used to. Check v/s (BP) 72/48, (T) 97.3, (P) 80, (R) 22...Called (physician)..." -1:55 a.m.: "...Resident is transferred to (Hospital "AA")..." -5:00 a.m.: "Resident came back from (Hospital "AA")...(with) new ordered (antibiotic)...still not response (sic) well this time..." R #1's Discharge Summary dated 04/01/14 from Hospital "AA" revealed R #1's [DIAGNOSES REDACTED]. R #1's Nurses Notes and Monthly Summary revealed the following: Nurses Notes: -From 04/13/14 at 5:00 p.m. through 04/17/14 at 2:00 p.m. revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 3 days and 21 hours. -From 04/20/14 at 6:00 p.m. through 04/26/14 until 10:00 a.m. revealed no documentation of R #1's condition, approximately 5 days and 16 hours. -From 04/29/14 at 2:23 p.m. through 05/05/14 until 2:30 a.m. revealed no documentation of R #1's condition, approximately 5 days and 12 hours. -05/05/14 at 2:30 a.m.: "Upon entering room, found resident'[MEDICAL CONDITION] large amount of coffee brown emesis (with) phlegm. Suction given @ this time. 02 sat 81% @ 3 LPM...Check v/s (T) 100.9, (BP) 100/67, (P) 91, (R) 24. Tylenol 650mg gave @ this time..." -2:45 a.m.: The physician was called regarding R #1's condition. -3:10 a.m.: "Call 911 to transfer resident to (Hospital "AA")..." -3:15 a.m.: "911 staff here to transfer resident to (Hospital "AA")..." Monthly Summary dated 05/01/14: -"Dry Skin" and "Mucous Membrane Moist." According to the American Medical Directors Association, www.amda.com, retrieved on 05/16/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Provider Report dated 05/05/14 from Hospital "AA" revealed: -3:49 a.m.: BP 89/65, P 85, R 16, T 99.3 -3:51 a.m.: "...lethargic, dehydrated..." -7:11 a.m.: BP 77/53, P 73, R 20, T 100.4 at 6:00 a.m. R #1's History and Physical dated 05/05/14 from Hospital "AA" revealed R #1 was diagnosed with [REDACTED]. R #1's Clinical Note dated 05/05/14 from Hospital "AA" revealed: -12:34 p.m.: "...After insertion of the (indwelling catheter) 300cc of purulent (pus) urine was returned..." -7:28 p.m.: "...Pt was admitted to ICU..." According to www.sepsisalliance.org on 05/12/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 05/12/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's Laboratory Test results dated 05/05/14 from Hospital "AA" revealed: Urinalysis: -"Urine appearance HAZY" Normal range "CLEAR." -"Urine pH 8.0 H" Normal range 5.5-7.0. -"Urine Protein 25 H" Normal range "NEGATIVE." -"Urine Blood 1+ H" Normal range "NEGATIVE." -"Urine [MEDICATION NAME] POSITIVE H" Normal range "NEGATIVE." -"(Urine) Leukocyte Esterase 2+ H" Normal range "NEGATIVE." -"Urine WBC 5-10 H" Normal range "NONE SEEN." -"(Urine) Transition Epith Cell FEW H" Normal range "NONE SEEN." -"Urine Bacteria 1+" Normal range "NONE SEEN." The Urinalysis dated 05/05/14 indicated R #1 had the potential to have a urinary tract infection. Blood Chemistry: -"BUN 21 H" Normal range 6-20. -"Glucose 135 H" Normal range 65-99. The Blood Chemistry dated 05/05/14 indicated R #1 had the potential to be dehydrated. R #1's Hospitalist Progress Note dated 05/06/14 from Hospital "AA" revealed: -24 hour total intake was 2085cc and total output was 855cc. -"...prognosis is very poor for this patient..." Observation on 05/07/14 at 10:20 a.m., at Hospital "AA", revealed R #1 lying in bed in ICU and unresponsive to surveyor's questions. On 05/07/14 at 10:25 a.m., MD "CC" from Hospital "AA" stated R #1 was "dehydrated" when admitted to the hospital on [DATE] and "[MEDICAL CONDITION] criteria." MD "CC" stated R #1's prognosis was "poor." On 05/08/14 at 11:00 a.m., SW "BB" from Hospital "AA" stated R #1 was discharged to another facility with hospice. The following information was gathered at Facility "DD": On 05/08/14 at 8:00 a.m., LVN "V" stated it was not the facility's policy to document or monitor a resident's intake and output, except for "fluid restriction." LVN "V" stated a resident's skin turgor and vital signs should be monitored to assess for dehydration and that if something was not "written down (in the nurses notes), it didn't happen." Surveyor asked LVN "V" how he would know a resident was at risk for dehydration. LVN "V" stated he would know by a resident's diagnosis. On 05/08/14 at 8:25 a.m., CNA "W" stated it was not the facility's policy to document or monitor a resident's intake and output. CNA "W" stated monitoring intake and output "should be done for residents" who were at risk for dehydration because a resident "could get dehydrated, decline in health, (and) organs won't work correctly." CNA "W" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "W" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:10 a.m., CNA "Y" stated it was not the facility's policy to document or monitor a resident's intake and output. Surveyor asked CNA "Y" how she would know a resident was at risk for dehydration. CNA "Y" stated a resident's ADL Flowsheet would alert staff that a resident was at risk for dehydration if the resident had "nectar liquids." CNA "Y" stated a resident who was dehydrated could get a "UTI" and "go to the hospital." CNA "Y" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "Y" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:25 a.m., CNA "X" stated residents who were at risk for dehydration were "monitored by the nurses." On 05/08/14 at 9:55 a.m., the DON stated nurses would know a resident was at risk for dehydration if the resident had "been in the hospital," nurses would "look at the whole picture," document the resident's condition on the "24 Hour Report" and do a "head to toe assessment." The DON stated the CNAs would know a resident was at risk for dehydration by looking at the "Care Plan" and "from the nurses." The DON stated, "It's a nursing thing to know if a resident is at risk for dehydration. We will monitor the resident." Surveyor asked the DON how staff monitored residents at risk for dehydration. The DON stated, "It depends on the resident. Nurses make rounds to monitor residents for dehydration...All residents are at risk for dehydration or they wouldn't be here." On 05/07/14 at 12:25 p.m., the DON stated the facility did not document or monitor resident's intake and output unless there was a physician's orders [REDACTED]." Review of the facility's 24 Hour Reports dated 04/24/14 through 05/05/14 revealed no documentation regarding R #1's hydration status. On 05/09/14 at 9:15 a.m., LVN "Z" stated it was not the facility's policy to monitor a resident's intake and output and staff "haven't done it." LVN "Z" stated, "I feel it's important to monitor (intake and output). A resident could get confused, a resident could die because of dehydration [MEDICAL CONDITION]." Surveyor asked LVN "Z" how she would know a resident was at risk for dehydration. LVN "Z" stated, "I don't know how I would know." LVN "Z" stated she would assess for dehydration by "dry skin, low output, mental status" and "would put it in the nurses notes. It should at least be charted every shift when there is a problem." On 05/09/14 at 9:40 a.m., LVN "A" stated a resident who was at risk for dehydration should be assessed for "change in status, sunken eyes, skin turgor" and there "should be charting to know if (a resident was) assessed for dehydration." R #3 R #3's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]., Cerebral Vascular Disease, Basal Ganglia Degeneration ([MEDICAL CONDITION] that fails to suppress unwanted movements), Paralytic Ileus (intestinal paralysis), Intestinal Obstruction, Tracheotomy, [MEDICAL CONDITION], Constipation, Dementia, Vascular Urinary Obstruction, Diarrhea and [MEDICAL CONDITION]. R #3's Quarterly MDS dated [DATE] revealed R #3 was unable to speak, rarely/never understood others nor was understood by others, had long and short term memory problems, was totally dependent with all ADLs and required the assistance of two persons with dressing and transfers, was incontinent of urine and had an [MEDICAL CONDITION] for bowel movements, tube feeding; received 51% or more nutrition through a [DEVICE] feedings; and received 501 cc/day or more fluid intake through a feeding tube, received oxygen therapy, tracheotomy care and suctioning. R #3's Nursing Assistant Care Plan dated 11/12/13 "Nutritional Status" revealed R #3 had a "tube feeder" and was incontinent of urine and had a [MEDICAL CONDITION]. R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed R #3: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 2:00 p.m.-10:00 p.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed an additional [DIAGNOSES REDACTED]." R #3's Care Plans dated 03/17/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T Dysphagia and [DEVICE] use .....Goal: Residents Nutritional Status will be maintained, Resident will have measures to decrease the potential of ...Dehydration ... Approach: Monitor for Signs and Symptoms of Dehydration, Dry Mucus Membranes, Decreased Output, changes in LOC, Change in Lab Values ..... ...Potential For Impaired Urinary Flow D/T HX. Urethral Obstruction ... Goal ...Resident Will Not Experience any Obstruction of Urinary Flow By Next Review ...Approach ...Monitor For Adequate Urinary Output Lower ABD Distention or Discomfort." R #3's Nurses Notes dated 03/20/14 through 05/08/14 revealed no documentation reflecting R #3 was assessed for Dehydration or Urinary Output. R #3's Nutritional Progress Note dated 03/28/14 revealed R #3 was NPO (nothing by mouth) and received [DEVICE] feedings with "[MEDICATION NAME]" (liquid nutrition) at 40 cc/hr for 22 hours and flushed with 340 cc of water every four hours. R #3's Monthly Summary dated 04/21/14 revealed: "Eating ...Total Dependence Why is this support needed: Tube Feeding due to volume depletion, dehydration, [MEDICAL CONDITION]." R #3's Laboratory Report dated 04/17/14 revealed: -Urea Nitrogen-29 H Reference range (7-25) -Creatinine-1.4 H Reference range (0.7-1.3). -eGFR-49 L Reference range (90>) The Laboratory Report dated 04/17/14 indicated R #3 had the potential to be dehydrated. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE], with the following Diagnoses: [REDACTED]. R #4's MDS dated [DATE] revealed R #4 was rarely/never understood by others nor understood others; cognitive skills for daily decision making were severely impaired-never/rarely made decisions; had total dependence with bed mobility and transfers and required two person assist; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; received 501 cc/day or more fluid intake through a [DEVICE]; had two stage two Pressure Ulcers; and medication included a diuretic. R #4's Nursing Assistant Care Plan dated 11/11/13 revealed: -"Nutritional Status" section revealed R #4 had [DEVICE] and was NPO, -"Elimination-Bladder, Elimination- Bowel" section revealed R #4 was incontinent of urine and bowel, -"Diet" section revealed R #4 had [MEDICAL CONDITION] feeding @35cc/hr. Flush with water per M.D. Orders. R #4's ADL Flow Sheet dated 05/01/14 through 05/31/14 revealed R #4: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 10:00 pm.-6:00 a.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #4's Care Plan dated 03/11/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T [DEVICE] Fed, NPO, and Dependent on Others for Nutrition and Hydration. .....Goal: Resident will have Measures to maintain Nutritional Status, be well Hydrated... Approach: Monitor for Dry Mucus Membranes, Fever, Poor Skin Turgor, Change in LOC, Changes in Lab Values." R #4's Care Plan entitled "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "-Goal: Consume Adequate Fluids -Approaches: Monitor s/s of dehydration, poor skin turgor, dry mucus membranes, offer fluids per GT, Monitor for [MEDICAL CONDITION]/dyspnea, Labs as ordered, Educate resident and/or family." R #4's Nurses Notes dated 11/05/13 through 05/06/14 revealed no documentation reflecting R #4 was assessed for Dehydration or Urinary Output. R #4's Consolidated Physician order [REDACTED]. R #4 had an order for [REDACTED]. Flush GT with 150cc of water every four hours. According to Mosby's 25th Edition: Nursing Drug Reference; [MEDICATION NAME] had the following precautions:...."dehydration." R #9 R #9's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. R #9's consolidated Physician order [REDACTED]. Once a day on the 15th of the month; 11:00 p.m.-7:00 a.m." R #9's Admission Care Plan dated 12/31/13 revealed; "Dehydration/Fluid Maintenance - Goal: Resident will consume adequate fluids..... - Monitor for signs/symptoms of dehydration... - Laboratory work as ordered... UTI FC (Urinary tract Infection/Urinary Catheter) - Goal: Resolve -Monitor every shift for UTI symptoms - Intake and Output." R #9's Laboratory Report dated 01/08/14 revealed: -Chloride-108 H (high) Reference range (98-107) previous results 08/24/13-101, -Urea Nitrogen-33 H Reference range (7-25) previous results 8/24/13-16, -Creatinine-1.5 H Reference range (0.7-1.3) previous results 8/24/13-1.1, -Osmolarity-293 H Reference range (260-278) previous results 8/24/13-277, -eGFR-44 L (low) Reference range (90>) (greater than 90) previous results 8/24/13-63. The Laboratory Report dated 01/08/14 indicated R #1 had the potential to be dehydrated. R #9's Care Plans dated 01/10/14 revealed there were no care plans specific to monitoring Intake and Output or Dehydration. R #9's Quarterly MDS dated [DATE] revealed R #9 had difficulty hearing, was sometimes understood and sometimes understood others, vision was moderately impaired,had both short and long term memory problems, cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required, required the assistance of two persons for transfers, required set up for meals, had an indwelling urinary catheter and a [MEDICAL CONDITION], and two unstageable decubitus ulcers. R #9's undated Nursing Assistant Care Plan regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan, but there was no specific care provision documented. R #9's Nursing Assistant Care Plan dated 05/01/14 regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan with specific instruction "I&O's Q shift." R #9's undated Summary/Registered Dietician Recommendations estimated fluid intake was 2000-2400 cc of fluids per day. R #9's medical record did not have any documentation revealing amount of fluid intake. R #9's ADL Flow Sheets revealed: 04/01/14-04/30/14: -There was no documentation for the entire month, on the 6:00 a.m.-2:00 p.m. shift for urine output measurement. - 04/06/14 through 04/08/14, there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. - 04/14/14 and 04/16/14 there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. Dated 05/01/14-05/31/14: -There was no documentation 05/01/14-05/06/14, on the 6:00 a.m.-2:00 p.m. or the 2:00 p.m.-10:00 p.m. shift. for urine output measurement. - 05/02/14 total documented urine output was 400 (no units of measurements noted). - 05/16/14 total urine output documented was 500. (no units of measurements noted). - 05/07/14 and 05/30/14 there was 600 total urine output documented.(no units of measurements noted). According to Lippincott's Nursing Procedures, 6th Edition, pages 376 and 377: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." On 05/09/14 at 9:30 a.m., LVN "M" said the policy of the facility was to monitor Intake and Output on residents with indwelling urinary catheters because of complications related to indwelling catheters such as obstruction, infection or dislodgement. The CNAs emptied the urinary catheter bags at the end of the shift and documented the output amount on the ADL sheet. The LVN "M" said, if the Output was not documented on the ADL sheet then the nurses would not be able to track how much out put that resident had for the shift. LVN "M" said, "if a resident were to become dehydrated or septic they would become delirious, get really sick and die and that (LVN "M") has seen a resident at the facility, become dehydrated in the past." LVN "M" said, "hydration was of top priority because people need fluids to stay alive." On 05/09/14 at 9:55 a.m., CNA "L" said that prior to yesterday the staff never had any formal training at the facility in measuring Intakes and Outputs for residents with urinary catheters. The CNA's knew what care to provide each resident by following the Nursing Assistant Care Plan. On 05/09/14 at 10:10 a.m., CNA "K" said, the CNA's were supposed to encourage residents to drink fluids. The CNAs were to empty out urinary catheter bags every shift and document on the resident's individual ADL sheet how much the resident urinated for that shift. If a resident became dehydrated, that could lead to constipation. On 05/09/14 at 1030 a.m., LVN "P" said the nurses were supposed to document in the nurses notes, and on the Intake and Output book all Intake and Outputs on residents with urinary catheters and residents that received [DEVICE] feedings. Residents at risk for dehydration were residents with dementia, [MEDICAL TREATMENT], thickened liquids. For Residents without urinary catheters the staff measured the Output by how many times the diaper had been changed, and if diaper was wet or soaked. The CNAs were to report any change in resident urination pattern, dark colored urine or foul odor to the nurse. The CNAs also emptied the urine bags every shift and documented the amount of output in the ADL sheet. If the CNAs were to not document how much out put the resident had at the end of the shift there would not be anyway for the nurses to know if the resident had voided. If a resident doesn't have adequate hydration they could become dehydrated and eventually expire. On 05/09/14 at 10:50 a.m., CNA"N"said, staff were in-serviced yesterday on how to determine if a resident was dehydrated. CNA"N"said, if a resident was dehydrated, the resident would be confused, not urinate and have poor skin elasticity. Residents with urinary catheters, the CNAs were supposed to write down the urine output every shift in the ADL book. The nurses and the aides would keep track of how much fluid the residents consumed by observing the meal trays to track how much the resident drank and encourage fluid intake. The CNAs knew what care to provide each resident by following the Nursing Assistant Care Plan. R #10 R #10's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #10's Quarterly MDS dated [DATE] revealed R #10 usually understood others and made self understood; had inattention and disorganized thinking; was independent with eating; was always continent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #10's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor for s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids - To nectar consistency. Resident has [DEVICE] (with) feeding @ HS...Monitor for [MEDICAL CONDITION]/dyspnea (swelling/air hunger..." R #10's Physician order [REDACTED]. -Regular diet with nectar thick liquids, -Offer 6-8 ounces of water thickened to nectar consistency four times a day with med pass, -Flush [DEVICE] with 150cc water every four hours, -Per [DEVICE]: "[MEDICATION NAME] 1.5 Cal (liquid nutrition) to infuse at 75cc/hr via pump x 10 hrs/day (8pm-6am) to provide...570cc free H2O..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." R #10's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #10's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #10's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #10's Nurses Notes revealed: -Dated 04/08/14 through 04/17/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. -There was no documentation from 04/17/14 through 04/23/14, approximately six days. -There was no documentation from 04/24/14 through 04/28/14, approximately four days. -There was no documentation from 04/29/14 through 05/02/14, approximately four days. -Dated 05/03/14 through 05/08/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. R #11 R #11's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #11's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor s/s of dehydration (poor skin turgor, dry mucous membranes,) Offer Fluids - To nectar consistency. Resident also receives feedings per [DEVICE]...Monitor for [MEDICAL CONDITION]/dyspnea..." R #11's Annual MDS dated [DATE] revealed R #11 sometimes understood others and sometimes made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); had inattention and disorganized thinking; was totally dependent on staff for eating; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #11's Physician order [REDACTED]. -"Offer 6-8 oz H2O thickened to nectar consistency QID with med pass" -Pureed diet, thicken liquids to nectar consistency -Per [DEVICE]: "[MEDICATION NAME] 1.5 (liquid nutrition) to infuse at 55cc/hr x 22 hrs/day total provided...919cc free H2O q shift..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -"Flush tube with 150cc H2O q4h..." R #11's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #11's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #11's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #11's Nurses Notes revealed: -Dated 04/21/14 through 04/24/14 revealed there was no documentation R #11 was assessed for poor skin turgor or dry mucous membran

Based on observation, interview and record review the facility failed to provide proper hydration for six Residents (R #1, R #3, R #4, R #9, R #10, R #11) of 16 Residents reviewed for hydration and infections. R #1 had a recent hospitalization with a [DIAGNOSES REDACTED].#1's condition. As a result of this, R #1 was sent to the hospital [MEDICAL CONDITION], dehydration and pus in his urine. R #1 was discharged to another facility from the hospital with hospice. The facility was aware that R #3, R #4, R #9, R #10 and R #11 were at risk for dehydration and did not consistently monitor and document those residents' conditions. These failures resulted in identification of an Immediate Jeopardy (IJ) on 05/08/14 at 10:50 a.m. While the IJ was removed on 05/09/14 at 12:15 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed 16 residents with [DEVICE]s, seven residents with indwelling urinary catheters and 123 residents with hydration issues at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to Facility "DD" on 01/23/13 with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 had no speech; rarely/never made self understood; sometimes understood others; had a moderately impaired cognition (decisions poor; cues/supervision required); was totally dependent on staff for eating, toilet use, bed mobility, locomotion, personal hygiene and bathing; was always incontinent of bowel and bladder; was not dehydrated; received oxygen therapy; had a feeding tube; received 51% or more nutrition through a feeding tube; and received 501 cc/day or more fluid intake through a feeding tube. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Dehydration/Fluid Maintenance. R #1's Care Plan dated 02/28/14 revealed: -"Care Plan for Residents with risks for Dehydration...Monitor s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids [DEVICE] as ordered..." R #1's Consolidated Physician order [REDACTED]. -03/13/14: "[MEDICATION NAME] (liquid nutrition via [DEVICE]) to infuse at 55cc/hr x 22hrs/day...to provide...949cc free H2O..." -04/09/13: "Flush [DEVICE] with 180cc H2O q4h..." -11/14/13: "Flush [DEVICE] with a least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -Magnesium oxide (supplement) 400mg TID. SE: electrolyte, fluid imbalances. -[MEDICATION NAME] (anticonvulsant) 250mg=10mL TID. SE: [MEDICAL CONDITION] (inflammation of the kidneys.) -Trazadone (antidepressant) 25mg BID. SE: Acute [MEDICAL CONDITION]. According to Lippincott's 2013 Nursing Procedures, Sixth Edition, page 729, documentation for gastrostomy tube feeding and complications included: -"On the intake and output record (I&O), note the date, time, and amount of each feeding and the water volume instilled..." -"Maintain total volumes for nutrients and water separately to allow calculation of nutrient intake..." -"In your notes, document the type of formula, the infusion method and rate, the patient's tolerance of the procedure and formula, and the amount of residual gastric contents..." -"...complications include...fluid and electrolyte imbalances..." R #1's "Enteral Flowsheets", "Enteral Meds Flowsheets", and "Medications Flowsheets" dated 04/2014 and 05/2014 revealed no documentation of R #1's total intake of tube feeding formula and water volumes instilled. R #1's ADL Flowsheets dated 04/2014 and 05/2014 revealed R #1 was "wet" three times on each shift: 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. The ADL Flowsheets did not describe what "wet" represented. R #1's Nurses Notes revealed the following entries dated 04/01/14: -1:30 a.m.: "Found resident responsed (sic) not like used to. Check v/s (BP) 72/48, (T) 97.3, (P) 80, (R) 22...Called (physician)..." -1:55 a.m.: "...Resident is transferred to (Hospital "AA")..." -5:00 a.m.: "Resident came back from (Hospital "AA")...(with) new ordered (antibiotic)...still not response (sic) well this time..." R #1's Discharge Summary dated 04/01/14 from Hospital "AA" revealed R #1's [DIAGNOSES REDACTED]. R #1's Nurses Notes and Monthly Summary revealed the following: Nurses Notes: -From 04/13/14 at 5:00 p.m. through 04/17/14 at 2:00 p.m. revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 3 days and 21 hours. -From 04/20/14 at 6:00 p.m. through 04/26/14 until 10:00 a.m. revealed no documentation of R #1's condition, approximately 5 days and 16 hours. -From 04/29/14 at 2:23 p.m. through 05/05/14 until 2:30 a.m. revealed no documentation of R #1's condition, approximately 5 days and 12 hours. -05/05/14 at 2:30 a.m.: "Upon entering room, found resident'[MEDICAL CONDITION] large amount of coffee brown emesis (with) phlegm. Suction given @ this time. 02 sat 81% @ 3 LPM...Check v/s (T) 100.9, (BP) 100/67, (P) 91, (R) 24. Tylenol 650mg gave @ this time..." -2:45 a.m.: The physician was called regarding R #1's condition. -3:10 a.m.: "Call 911 to transfer resident to (Hospital "AA")..." -3:15 a.m.: "911 staff here to transfer resident to (Hospital "AA")..." Monthly Summary dated 05/01/14: -"Dry Skin" and "Mucous Membrane Moist." According to the American Medical Directors Association, www.amda.com, retrieved on 05/16/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Provider Report dated 05/05/14 from Hospital "AA" revealed: -3:49 a.m.: BP 89/65, P 85, R 16, T 99.3 -3:51 a.m.: "...lethargic, dehydrated..." -7:11 a.m.: BP 77/53, P 73, R 20, T 100.4 at 6:00 a.m. R #1's History and Physical dated 05/05/14 from Hospital "AA" revealed R #1 was diagnosed with [REDACTED]. R #1's Clinical Note dated 05/05/14 from Hospital "AA" revealed: -12:34 p.m.: "...After insertion of the (indwelling catheter) 300cc of purulent (pus) urine was returned..." -7:28 p.m.: "...Pt was admitted to ICU..." According to www.sepsisalliance.org on 05/12/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 05/12/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's Laboratory Test results dated 05/05/14 from Hospital "AA" revealed: Urinalysis: -"Urine appearance HAZY" Normal range "CLEAR." -"Urine pH 8.0 H" Normal range 5.5-7.0. -"Urine Protein 25 H" Normal range "NEGATIVE." -"Urine Blood 1+ H" Normal range "NEGATIVE." -"Urine [MEDICATION NAME] POSITIVE H" Normal range "NEGATIVE." -"(Urine) Leukocyte Esterase 2+ H" Normal range "NEGATIVE." -"Urine WBC 5-10 H" Normal range "NONE SEEN." -"(Urine) Transition Epith Cell FEW H" Normal range "NONE SEEN." -"Urine Bacteria 1+" Normal range "NONE SEEN." The Urinalysis dated 05/05/14 indicated R #1 had the potential to have a urinary tract infection. Blood Chemistry: -"BUN 21 H" Normal range 6-20. -"Glucose 135 H" Normal range 65-99. The Blood Chemistry dated 05/05/14 indicated R #1 had the potential to be dehydrated. R #1's Hospitalist Progress Note dated 05/06/14 from Hospital "AA" revealed: -24 hour total intake was 2085cc and total output was 855cc. -"...prognosis is very poor for this patient..." Observation on 05/07/14 at 10:20 a.m., at Hospital "AA", revealed R #1 lying in bed in ICU and unresponsive to surveyor's questions. On 05/07/14 at 10:25 a.m., MD "CC" from Hospital "AA" stated R #1 was "dehydrated" when admitted to the hospital on [DATE] and "[MEDICAL CONDITION] criteria." MD "CC" stated R #1's prognosis was "poor." On 05/08/14 at 11:00 a.m., SW "BB" from Hospital "AA" stated R #1 was discharged to another facility with hospice. The following information was gathered at Facility "DD": On 05/08/14 at 8:00 a.m., LVN "V" stated it was not the facility's policy to document or monitor a resident's intake and output, except for "fluid restriction." LVN "V" stated a resident's skin turgor and vital signs should be monitored to assess for dehydration and that if something was not "written down (in the nurses notes), it didn't happen." Surveyor asked LVN "V" how he would know a resident was at risk for dehydration. LVN "V" stated he would know by a resident's diagnosis. On 05/08/14 at 8:25 a.m., CNA "W" stated it was not the facility's policy to document or monitor a resident's intake and output. CNA "W" stated monitoring intake and output "should be done for residents" who were at risk for dehydration because a resident "could get dehydrated, decline in health, (and) organs won't work correctly." CNA "W" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "W" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:10 a.m., CNA "Y" stated it was not the facility's policy to document or monitor a resident's intake and output. Surveyor asked CNA "Y" how she would know a resident was at risk for dehydration. CNA "Y" stated a resident's ADL Flowsheet would alert staff that a resident was at risk for dehydration if the resident had "nectar liquids." CNA "Y" stated a resident who was dehydrated could get a "UTI" and "go to the hospital." CNA "Y" stated documentation for a resident who was incontinent of urine included writing the letters "D" for dry, "W" for wet, and "S" for saturated. CNA "Y" stated she did not know how to measure the quantity of an incontinent resident's urine to determine if the resident urinated in sufficient amounts. On 05/08/14 at 9:25 a.m., CNA "X" stated residents who were at risk for dehydration were "monitored by the nurses." On 05/08/14 at 9:55 a.m., the DON stated nurses would know a resident was at risk for dehydration if the resident had "been in the hospital," nurses would "look at the whole picture," document the resident's condition on the "24 Hour Report" and do a "head to toe assessment." The DON stated the CNAs would know a resident was at risk for dehydration by looking at the "Care Plan" and "from the nurses." The DON stated, "It's a nursing thing to know if a resident is at risk for dehydration. We will monitor the resident." Surveyor asked the DON how staff monitored residents at risk for dehydration. The DON stated, "It depends on the resident. Nurses make rounds to monitor residents for dehydration...All residents are at risk for dehydration or they wouldn't be here." On 05/07/14 at 12:25 p.m., the DON stated the facility did not document or monitor resident's intake and output unless there was a physician's orders [REDACTED]." Review of the facility's 24 Hour Reports dated 04/24/14 through 05/05/14 revealed no documentation regarding R #1's hydration status. On 05/09/14 at 9:15 a.m., LVN "Z" stated it was not the facility's policy to monitor a resident's intake and output and staff "haven't done it." LVN "Z" stated, "I feel it's important to monitor (intake and output). A resident could get confused, a resident could die because of dehydration [MEDICAL CONDITION]." Surveyor asked LVN "Z" how she would know a resident was at risk for dehydration. LVN "Z" stated, "I don't know how I would know." LVN "Z" stated she would assess for dehydration by "dry skin, low output, mental status" and "would put it in the nurses notes. It should at least be charted every shift when there is a problem." On 05/09/14 at 9:40 a.m., LVN "A" stated a resident who was at risk for dehydration should be assessed for "change in status, sunken eyes, skin turgor" and there "should be charting to know if (a resident was) assessed for dehydration." R #3 R #3's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]., Cerebral Vascular Disease, Basal Ganglia Degeneration ([MEDICAL CONDITION] that fails to suppress unwanted movements), Paralytic Ileus (intestinal paralysis), Intestinal Obstruction, Tracheotomy, [MEDICAL CONDITION], Constipation, Dementia, Vascular Urinary Obstruction, Diarrhea and [MEDICAL CONDITION]. R #3's Quarterly MDS dated [DATE] revealed R #3 was unable to speak, rarely/never understood others nor was understood by others, had long and short term memory problems, was totally dependent with all ADLs and required the assistance of two persons with dressing and transfers, was incontinent of urine and had an [MEDICAL CONDITION] for bowel movements, tube feeding; received 51% or more nutrition through a [DEVICE] feedings; and received 501 cc/day or more fluid intake through a feeding tube, received oxygen therapy, tracheotomy care and suctioning. R #3's Nursing Assistant Care Plan dated 11/12/13 "Nutritional Status" revealed R #3 had a "tube feeder" and was incontinent of urine and had a [MEDICAL CONDITION]. R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed R #3: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 2:00 p.m.-10:00 p.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #3's ADL Flowsheet dated 05/01/14 through 05/31/14 revealed an additional [DIAGNOSES REDACTED]." R #3's Care Plans dated 03/17/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T Dysphagia and [DEVICE] use .....Goal: Residents Nutritional Status will be maintained, Resident will have measures to decrease the potential of ...Dehydration ... Approach: Monitor for Signs and Symptoms of Dehydration, Dry Mucus Membranes, Decreased Output, changes in LOC, Change in Lab Values ..... ...Potential For Impaired Urinary Flow D/T HX. Urethral Obstruction ... Goal ...Resident Will Not Experience any Obstruction of Urinary Flow By Next Review ...Approach ...Monitor For Adequate Urinary Output Lower ABD Distention or Discomfort." R #3's Nurses Notes dated 03/20/14 through 05/08/14 revealed no documentation reflecting R #3 was assessed for Dehydration or Urinary Output. R #3's Nutritional Progress Note dated 03/28/14 revealed R #3 was NPO (nothing by mouth) and received [DEVICE] feedings with "[MEDICATION NAME]" (liquid nutrition) at 40 cc/hr for 22 hours and flushed with 340 cc of water every four hours. R #3's Monthly Summary dated 04/21/14 revealed: "Eating ...Total Dependence Why is this support needed: Tube Feeding due to volume depletion, dehydration, [MEDICAL CONDITION]." R #3's Laboratory Report dated 04/17/14 revealed: -Urea Nitrogen-29 H Reference range (7-25) -Creatinine-1.4 H Reference range (0.7-1.3). -eGFR-49 L Reference range (90>) The Laboratory Report dated 04/17/14 indicated R #3 had the potential to be dehydrated. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE], with the following Diagnoses: [REDACTED]. R #4's MDS dated [DATE] revealed R #4 was rarely/never understood by others nor understood others; cognitive skills for daily decision making were severely impaired-never/rarely made decisions; had total dependence with bed mobility and transfers and required two person assist; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; received 501 cc/day or more fluid intake through a [DEVICE]; had two stage two Pressure Ulcers; and medication included a diuretic. R #4's Nursing Assistant Care Plan dated 11/11/13 revealed: -"Nutritional Status" section revealed R #4 had [DEVICE] and was NPO, -"Elimination-Bladder, Elimination- Bowel" section revealed R #4 was incontinent of urine and bowel, -"Diet" section revealed R #4 had [MEDICAL CONDITION] feeding @35cc/hr. Flush with water per M.D. Orders. R #4's ADL Flow Sheet dated 05/01/14 through 05/31/14 revealed R #4: -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, 2:00 p.m.-10:00 p.m. shift and the 10:00 p.m..-6:00 a.m. shift from 05/01/14 through 05/05/14. -Was incontinent of urine three episodes on the 6:00 a.m.-2:00 p.m. shift, and the 10:00 pm.-6:00 a.m. shift on 05/06/14 and 05/07/14. All incontinent episodes were documented as "wet." R #4's Care Plan dated 03/11/14 revealed "Potential for Impaired Nutritional Status, .....Dehydration R/T [DEVICE] Fed, NPO, and Dependent on Others for Nutrition and Hydration. .....Goal: Resident will have Measures to maintain Nutritional Status, be well Hydrated... Approach: Monitor for Dry Mucus Membranes, Fever, Poor Skin Turgor, Change in LOC, Changes in Lab Values." R #4's Care Plan entitled "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "-Goal: Consume Adequate Fluids -Approaches: Monitor s/s of dehydration, poor skin turgor, dry mucus membranes, offer fluids per GT, Monitor for [MEDICAL CONDITION]/dyspnea, Labs as ordered, Educate resident and/or family." R #4's Nurses Notes dated 11/05/13 through 05/06/14 revealed no documentation reflecting R #4 was assessed for Dehydration or Urinary Output. R #4's Consolidated Physician order [REDACTED]. R #4 had an order for [REDACTED]. Flush GT with 150cc of water every four hours. According to Mosby's 25th Edition: Nursing Drug Reference; [MEDICATION NAME] had the following precautions:...."dehydration." R #9 R #9's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. R #9's consolidated Physician order [REDACTED]. Once a day on the 15th of the month; 11:00 p.m.-7:00 a.m." R #9's Admission Care Plan dated 12/31/13 revealed; "Dehydration/Fluid Maintenance - Goal: Resident will consume adequate fluids..... - Monitor for signs/symptoms of dehydration... - Laboratory work as ordered... UTI FC (Urinary tract Infection/Urinary Catheter) - Goal: Resolve -Monitor every shift for UTI symptoms - Intake and Output." R #9's Laboratory Report dated 01/08/14 revealed: -Chloride-108 H (high) Reference range (98-107) previous results 08/24/13-101, -Urea Nitrogen-33 H Reference range (7-25) previous results 8/24/13-16, -Creatinine-1.5 H Reference range (0.7-1.3) previous results 8/24/13-1.1, -Osmolarity-293 H Reference range (260-278) previous results 8/24/13-277, -eGFR-44 L (low) Reference range (90>) (greater than 90) previous results 8/24/13-63. The Laboratory Report dated 01/08/14 indicated R #1 had the potential to be dehydrated. R #9's Care Plans dated 01/10/14 revealed there were no care plans specific to monitoring Intake and Output or Dehydration. R #9's Quarterly MDS dated [DATE] revealed R #9 had difficulty hearing, was sometimes understood and sometimes understood others, vision was moderately impaired,had both short and long term memory problems, cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required, required the assistance of two persons for transfers, required set up for meals, had an indwelling urinary catheter and a [MEDICAL CONDITION], and two unstageable decubitus ulcers. R #9's undated Nursing Assistant Care Plan regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan, but there was no specific care provision documented. R #9's Nursing Assistant Care Plan dated 05/01/14 regarding "Elimination-Bladder" care revealed "catheter" checked off as part of the care plan with specific instruction "I&O's Q shift." R #9's undated Summary/Registered Dietician Recommendations estimated fluid intake was 2000-2400 cc of fluids per day. R #9's medical record did not have any documentation revealing amount of fluid intake. R #9's ADL Flow Sheets revealed: 04/01/14-04/30/14: -There was no documentation for the entire month, on the 6:00 a.m.-2:00 p.m. shift for urine output measurement. - 04/06/14 through 04/08/14, there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. - 04/14/14 and 04/16/14 there was no documentation of urine output measurement on the 2:00 p.m.-10:00 p.m. shift. Dated 05/01/14-05/31/14: -There was no documentation 05/01/14-05/06/14, on the 6:00 a.m.-2:00 p.m. or the 2:00 p.m.-10:00 p.m. shift. for urine output measurement. - 05/02/14 total documented urine output was 400 (no units of measurements noted). - 05/16/14 total urine output documented was 500. (no units of measurements noted). - 05/07/14 and 05/30/14 there was 600 total urine output documented.(no units of measurements noted). According to Lippincott's Nursing Procedures, 6th Edition, pages 376 and 377: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." On 05/09/14 at 9:30 a.m., LVN "M" said the policy of the facility was to monitor Intake and Output on residents with indwelling urinary catheters because of complications related to indwelling catheters such as obstruction, infection or dislodgement. The CNAs emptied the urinary catheter bags at the end of the shift and documented the output amount on the ADL sheet. The LVN "M" said, if the Output was not documented on the ADL sheet then the nurses would not be able to track how much out put that resident had for the shift. LVN "M" said, "if a resident were to become dehydrated or septic they would become delirious, get really sick and die and that (LVN "M") has seen a resident at the facility, become dehydrated in the past." LVN "M" said, "hydration was of top priority because people need fluids to stay alive." On 05/09/14 at 9:55 a.m., CNA "L" said that prior to yesterday the staff never had any formal training at the facility in measuring Intakes and Outputs for residents with urinary catheters. The CNA's knew what care to provide each resident by following the Nursing Assistant Care Plan. On 05/09/14 at 10:10 a.m., CNA "K" said, the CNA's were supposed to encourage residents to drink fluids. The CNAs were to empty out urinary catheter bags every shift and document on the resident's individual ADL sheet how much the resident urinated for that shift. If a resident became dehydrated, that could lead to constipation. On 05/09/14 at 1030 a.m., LVN "P" said the nurses were supposed to document in the nurses notes, and on the Intake and Output book all Intake and Outputs on residents with urinary catheters and residents that received [DEVICE] feedings. Residents at risk for dehydration were residents with dementia, [MEDICAL TREATMENT], thickened liquids. For Residents without urinary catheters the staff measured the Output by how many times the diaper had been changed, and if diaper was wet or soaked. The CNAs were to report any change in resident urination pattern, dark colored urine or foul odor to the nurse. The CNAs also emptied the urine bags every shift and documented the amount of output in the ADL sheet. If the CNAs were to not document how much out put the resident had at the end of the shift there would not be anyway for the nurses to know if the resident had voided. If a resident doesn't have adequate hydration they could become dehydrated and eventually expire. On 05/09/14 at 10:50 a.m., CNA"N"said, staff were in-serviced yesterday on how to determine if a resident was dehydrated. CNA"N"said, if a resident was dehydrated, the resident would be confused, not urinate and have poor skin elasticity. Residents with urinary catheters, the CNAs were supposed to write down the urine output every shift in the ADL book. The nurses and the aides would keep track of how much fluid the residents consumed by observing the meal trays to track how much the resident drank and encourage fluid intake. The CNAs knew what care to provide each resident by following the Nursing Assistant Care Plan. R #10 R #10's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #10's Quarterly MDS dated [DATE] revealed R #10 usually understood others and made self understood; had inattention and disorganized thinking; was independent with eating; was always continent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #10's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor for s/s of dehydration (Poor skin turgor, dry mucous membranes,) Offer fluids - To nectar consistency. Resident has [DEVICE] (with) feeding @ HS...Monitor for [MEDICAL CONDITION]/dyspnea (swelling/air hunger..." R #10's Physician order [REDACTED]. -Regular diet with nectar thick liquids, -Offer 6-8 ounces of water thickened to nectar consistency four times a day with med pass, -Flush [DEVICE] with 150cc water every four hours, -Per [DEVICE]: "[MEDICATION NAME] 1.5 Cal (liquid nutrition) to infuse at 75cc/hr via pump x 10 hrs/day (8pm-6am) to provide...570cc free H2O..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." R #10's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #10's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #10's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #10's Nurses Notes revealed: -Dated 04/08/14 through 04/17/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. -There was no documentation from 04/17/14 through 04/23/14, approximately six days. -There was no documentation from 04/24/14 through 04/28/14, approximately four days. -There was no documentation from 04/29/14 through 05/02/14, approximately four days. -Dated 05/03/14 through 05/08/14 revealed there was no documentation R #10 was assessed for poor skin turgor, dry mucous membranes, [MEDICAL CONDITION] or dyspnea. R #11 R #11's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #11's "Care Plan for Residents with risks for Dehydration" dated 02/28/14 revealed: "...Approaches: Monitor s/s of dehydration (poor skin turgor, dry mucous membranes,) Offer Fluids - To nectar consistency. Resident also receives feedings per [DEVICE]...Monitor for [MEDICAL CONDITION]/dyspnea..." R #11's Annual MDS dated [DATE] revealed R #11 sometimes understood others and sometimes made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); had inattention and disorganized thinking; was totally dependent on staff for eating; was always incontinent of bowel and bladder; had a [DEVICE]; received 51% or more nutrition through a [DEVICE]; and received 501 cc/day or more fluids through a [DEVICE]. R #11's Physician order [REDACTED]. -"Offer 6-8 oz H2O thickened to nectar consistency QID with med pass" -Pureed diet, thicken liquids to nectar consistency -Per [DEVICE]: "[MEDICATION NAME] 1.5 (liquid nutrition) to infuse at 55cc/hr x 22 hrs/day total provided...919cc free H2O q shift..." -"Flush [DEVICE] with at least 15cc H2O, administer med, flush with at least 15cc H2O. Continue same procedure until all meds are administered, then flush with at least 15cc H2O q shift..." -"Flush tube with 150cc H2O q4h..." R #11's Dietary Flowsheets dated 04/2014 and 05/2014 revealed: "Offer 6-8 oz H2O thickened to nectar consistency QID with med pass." There was no documentation of how many ounces of water R #10 consumed. R #11's Medications and Enteral Meds Flowsheets dated 05/2014 revealed there was no total intake of tube feeding and water volumes instilled. R #11's ADL Flowsheets dated 04/2014 and 05/2014 revealed there was no documentation of how many ounces of fluid R #10 consumed with meals. R #11's Nurses Notes revealed: -Dated 04/21/14 through 04/24/14 revealed there was no documentation R #11 was assessed for poor skin turgor or dry mucous membranes. -Dated 04/26/14 through 05/05/14 revealed th

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for four Residents (R #1, #2, #5 and #7) of seven Residents reviewed for hydration. The Administrator failed to: 1) Implement policies and procedures for hydration and I&O. 2) Supervise the Director Of Nurses (DON) to ensure she followed the facility's neglect, hydration and I&O policy. The DON failed to ensure effective interventions were in place to protect R #1 from dehydration [MEDICAL CONDITION]. The DON failed to: 1) Develop and implement policies and procedures for hydration and I&O. 2) Supervise the nursing staff to ensure that the nursing staff were consistently assessing R #1, consistently documenting those assessments, and ensuring R #1's Physician was aware of R #1's lab results. -The facility was aware that R #1 was at risk for dehydration and UTI. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -The facility was aware that R #1 had cloudy, dark brown, foul smelling urine and was dehydrated. -The facility did not consistently assess or monitor R #1's condition. -The facility did not ensure R #1 received timely and appropriate medical intervention to treat his urinary infection and change in condition. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. R #2 was not consistently provided fluids. R #5 was not consistently provided fluids. R #7 was not consistently provided fluids. These deficient practices placed 43 residents monitored for hydration at risk of not receiving proper assessments, care and services required to prevent delay in treatment, complications or hospitalization . Findings were: R #1: R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." R #2: R #2's Face Sheet dated 10/25/12 indicated R #2 was admitted to the facility on [DATE]. R #2 was [AGE] years old. R #2's Consolidated physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. R #2 was prescribed a regular diet and fluids, with no fluid restrictions. R #2's Annual Minimum Data Set ((MDS) dated [DATE] indicated R #2 responded adequately to simple, direct communication and was able to make concrete requests. R #2's cognition was moderately impaired (cues and supervision required). R #2 was totally dependent for eating and drinking with assistance from one staff person. R #2's range of motion was impaired on her right and left upper and lower extremities. R #2 was at risk of developing a pressure ulcer. R #2 had received anti-anxiety, antidepressant and diuretics. R #2's Quarterly MDS dated [DATE] indicated R #2 responded adequately to simple, direct communication and was able to make concrete requests. R #2's cognition was moderately impaired (cues and supervision required). R #2 was totally dependent for eating and drinking with assistance from one staff person. R #2's range of motion was impaired on her right and left upper and lower extremities. R #2 was at risk of developing a pressure ulcer. R #2 had received antidepressants and diuretics. R #2's Activities of Daily Living (ADLs, eating, drinking, bathing, grooming, oral hygiene, incontinent care) Care Plan dated 12/16/13 revealed R #2 required total assistance with ADL needs secondary to [MEDICAL CONDITION] and debility (weak/feeble). The goal of the Care Plan was for all of R #2's needs to be met. The approaches to be utilized were for nursing staff to anticipate and assist with all ADL needs. Range of motion provided with ADLs, oral care every morning and after meals, transfer with one staff and monitor R #2 for further decline in ADLs to determine further assistance to meet needs. R #2's Impaired Skin Integrity due to incontinence of bowel and bladder elimination and [DIAGNOSES REDACTED].#2 adequate nutrition and hydration. During observation of R #2's room during initial tour on 02/27/14 at 3:40 p.m. revealed R #2 was lying in her bed. R #2's water pitcher was on a bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. The water pitcher was half full. There was not a drinking glass available. R #2 stated she was thirsty. Observation of R #2's room on 02/27/14 at 6:25 p.m. revealed R #2's water pitcher was on a bedside table located at the foot of R #2's bed. R #2 was sitting up in a wheelchair in the middle of the room. R #2 was approximately three feet from the bedside table and the water. The water pitcher was half full. There was not an available glass next to the water pitcher. Observation and subsequent interview with R #2 on 02/28/14 at 1:30 p.m. revealed R #2 lying in bed. R #2's water pitcher was still on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. The water pitcher was half full. There was not a drinking glass available. R #2 stated she was thirsty. R #2 stated, "I don't have any water, but I want some." Observation of R #2's room on 03/03/14 at 11:40 p.m. revealed R #2's water pitcher was on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. There was an empty plastic glass next to the water pitcher. Observation of R #2 in the dining room on 03/03/14 at 12:35 p.m. revealed R #2 sitting at a dining room table. An unknown staff placed a glass (approximately 6 ounces) of water in front of R #2. R #2 drank 3/4s of the glass of water all at one time. R #2 was given another glass of water with her meal and R #2 drank the entire glass of water during her meal. Observation of R #2's room on 03/03/14 at 4:10 p.m. revealed R #2's water pitcher was on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. There was an empty plastic glass next to the water pitcher. R #5 R #5's Face Sheet dated 02/28/13 indicated R #5 was admitted to the facility on [DATE]. R #5 was [AGE] years old. R #5's Consolidated physician's orders [REDACTED].#5 [DIAGNOSES REDACTED]. R #5 was prescribed a pureed bland, low fiber diet without any fluid restrictions. R #5's Annual MDS dated [DATE] revealed R #5 was rarely or never understood and rarely or never understood others. R #5 cognition was severely impaired (never/rarely made decisions). R #5 was totally dependent on one staff person for eating and drinking. R #5 had limited range of motion to his left and right lower extremities. R #5 had a stage two pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). R #5 received antidepressants and anti-psychotic medications. R #5's Quarterly MDS dated [DATE] revealed R #5 was rarely or never understood and rarely or never understood others. R #5 cognition was severely impaired. R #5 was totally dependent on one staff person for eating and drinking. R #5 had limited range of motion to his left and right lower extremities. R #5 was at risk of developing pressure ulcers. R #5 received antidepressants and anti-psychotic medications. R #5's ADL Care Plan dated 11/25/13 revealed R #5 had self care deficit due to cognitive deficits due to dementia and required total assistance with ADLs. The goal for R #5 was for R #5 to be well dressed and groomed and comfortable in his environment. The approaches to be utilized by the nursing staff were to explain all procedures before proceeding, assist R #5 with bed mobility every two hours, assist with transfers per two staff and a mechanical lift, assist with dressing, grooming showering, personal hygiene and toileting and encourage activities. Hydration was not listed as an ADL that required assistance by nursing staff. R #5's Care Plan dated 11/25/13 for bowel elimination due to [DIAGNOSES REDACTED].#5 would have a bowel movement every two to three days. The approaches to by utilized by nursing staff were to monitor bowel movements every shift, monitor for abdominal distention, bowel sounds, hard stools or R #5's report of abdominal pressure or fullness, provide adequate nutrition and hydration and report to Physician any unrelieved constipation. During observation and subsequent interview in R #5's room during initial tour on 02/27/14 at 5:00 p.m. with Licensed Vocational Nurse (LVN) "P" present revealed R #5 was lying in his bed. R #5's mouth was open and around his lips was a white dried substance. R #5's water pitcher was next to his bed on a nightstand. There was not a drinking glass available. R #5 stated he was thirsty. LVN "P" stated R #5 had not been eating or drinking because he had diarrhea. LVN "P" did not offer R #5 fluid and continued with the initial tour. During observation and subsequent interview in R #5's room on 02/27/14 at 6:30 p.m. R #5 was being assisted with eating and given fluids by CNA "Q." CNA "Q" stated R #5 ate his food and drank his fluids "good." Surveyor observed R #5 gulp 3/4 of a glass (approximately 6 ounces) of iced tea through a straw. R #5 completed drinking the glass of tea and R #5 drank 1/2 of another glass of iced tea. During observation and subsequent interview with R #5 in the lobby area on the 2nd floor R #5 was observed in his geri-chair (chair used for positioning). R #5's mouth was open and his lips were dry. R #5 said he was "thirsty, for cold water. Ice water." LVN "P" said in an interview on 03/03/14 at 4:01 p.m. she began her shift at 2:00 p.m. and R #5 had not been offered anything to drink since she had arrived at 2:00 p.m. R #7 R #7's Face Sheet (not dated) indicated R #7 was admitted to the facility on [DATE]. R #7 was [AGE] years old. R #7's Consolidated physician's orders [REDACTED].#7 had [DIAGNOSES REDACTED]. R #7 was prescribed a Regular low Concentrated Diet with thin liquids, there were not any fluid restrictions. R #7's Significant Change of Status MDS dated [DATE] indicated R #7 had clear speech, usually understood and was usually understood by others. R #7 required staff assistance with set-up of meal and fluids only and was independent with eating and drinking. R #7's functional range of motion was not impaired on his right or left upper extremities. R #7 had a Urinary Tract Infection within 30 days prior to MDS. R #7 was at risk of developing a pressure ulcer. R #7 had received diuretic and antibiotic medications seven days prior to the assessment. R #7's Care Area Assessment Summary revealed R #7 triggered for dehydration and fluid maintenance. R #7's Readmission/Return MDS dated [DATE] indicated R #7 had clear speech, usually understood and was usually understood by others. R #7 required staff assistance with set-up of meal and fluids only and was independent with eating and drinking. R #7's functional range of motion was impaired on his left lower extremity from a [MEDICAL CONDITION]. R #7 was at risk of developing a pressure ulcer. R #7 had received anti-anxiety, anticoagulant and antibiotic medications seven days prior to the assessment. Review of R #7's UTI Care Plan dated 01/17/14 revealed R #7 was at risk for UTIs due to R #7 had a history of [REDACTED].#7 to have no signs or symptoms of a UTI. The approaches to be utilized by the nursing staff and Certified Nurse Aides (CNAs) were to monitor labs as ordered, encourage fluid intake and monitor for signs and symptoms of UTI. R #7 stated in an interview on 03/03/14 at 2:00 p.m. he was not capable of transferring himself to and from his wheelchair. R #7 stated he was often without water during the day. R #7 said he had asked the CNAs to bring him water and they told him "later" because they were busy. When the day shift filled the water pitcher it was only with water, not fresh ice. R #7 stated the night shift usually filled up the water pitcher with ice and water. On 02/28/14 at 3:20 p.m. CNA "R" stated she worked on Hall 500 and the nurses tell the CNAs who is at risk of dehydration, who to push fluids to and encourage to drink. There is not a list of residents for the CNAs to know who is at risk of dehydration. CNA "R" stated water is passed out to the rooms during every shift and fluids are offered to residents during meals. CNA "R" stated the water pitchers were "supposed to be by the resident's bedside" or the resident would be at risk of dehydration. CNA "R" said residents were at risk of getting dehydrated if they were not able to reach their water. CNA "R" said water was offered to residents every two or three hours but there was not a schedule. CNA "R" stated the CNAs did not write down how much fluids were consumed for residents who were at risk of dehydration. On 02/28/14 at 3:40 p.m. CNA "S" stated she worked on Hall 200. CNA "S" stated the CNAs did not write down the intake of residents who were at risk of dehydration. CNA "S" stated there was not a list of residents who were at risk of dehydration. CNA "S" said, "I feel all residents are at risk for dehydration." CNA "S" said CNAs were to make sure water was at the bedside tables for all residents. CNA "S" said all residents on Hall 200 were able to reach their water. On 02/28/14 at 4:00 p.m. CNA "T" stated she worked on the second floor and CNAs were to offer fluids to residents every two hours. CNA "T" stated she reported to the Charge Nurse if a resident was not drinking. CNA "T" stated residents were at risk of dehydration if they were not able to reach their water. On 02/28/14 at 4:15 p.m. LVN "U" stated she worked on the second floor and there was not a list of residents who were at risk of dehydration for the CNAs to know who was at risk for dehydration. Confidential Interviewee (CI) "ZZ" stated in an interview he/she had been at the facility to visit a family member and the family member was sitting in the dining room at a table. CI "ZZ" said other residents were also present but there were not any staff present. CI "ZZ" said the family member stated he/she was thirsty. CI "ZZ" said he/she got up to get the family member water and other residents began stating they were thirsty. CI "ZZ" said another resident who was capable of walking got up and began passing water out to the residents. CI "ZZ" stated he/she had observed residents sitting in the dining room on several occasions without any fluids available. CI "ZZ" said he/she had observed her/his family member on several occasions without water in the room. The water pitcher may have been in the family member's room but it was out of reach, empty or the water was dirty. CI "ZZ" said the water pitcher was too heavy for the family member to lift. CI "WW" stated in an interview he/she visited his/her family member once or twice a week. CI "WW's" family member's water was always out of reach and the family member was always thirsty when CI "WW" arrived. CI "WW" said the family member would drink an eight ounce glass of water and ask for more. On 03/03/14 at 1:35 p.m. the Director of Nurses (DON) stated in an interview water pitchers were to be within reach of residents. The DON said if residents were in bed the water should be on the bedside table within reach of the resident. Staff were to offer fluids each time a staff person whet into a resident's room, with meals and during supplements. The DON said if a glass was not available for residents to drink, the water pitcher had an opening that allowed residents to drink directly from the water pitcher and a hole for a straw. The DON did not respond when asked what a resident would do if the water pitcher was to heavy to lift. On 03/03/14 at 1:45 p.m., the DON stated she was directly responsible for all of the nursing staff (CNAs, LVNs and RNs). The DON said on the weekends a Registered Nurse (RN) was available and if there were any issues the RN contacted the ADON who notified the DON. On 03/03/14 at 3:35 p.m. the Administrator stated in an interview the DON was responsible for nursing staff. The Administrator stated she (Administrator) was responsible for "all staff." The Administrator stated, "the Administrator is ultimately responsible for everything." The Administrator said she monitored the DON by reviewing incident and accident reports, attending morning meetings, attending Quality Assurance and Assessment meetings and reviewing concern forms submitted by family members. The Administrator said the DON had daily clinical meeting and discussed laboratory results. The Administrator said the nursing staff were to notify a resident's physician and responsible party when a resident had a change of condition. The Administrat

Based on observation, interview and record review the facility failed to provide proper hydration for four Residents (R #1, #2, #5 and #7) of seven Residents reviewed for hydration. R #1: -The facility was aware that R #1 was at risk for dehydration and UTI. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -The facility was aware that R #1 had cloudy, dark brown, foul smelling urine and was dehydrated. -The facility did not consistently assess or monitor R #1's condition. -The facility did not ensure R #1 received timely and appropriate medical intervention to treat his urinary infection and change in condition. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. R #2 was not consistently provided fluids. R #5 was not consistently provided fluids. R #7 was not consistently provided fluids. This failure could place the 43 residents who require monitoring for hydration at risk of skin breakdown, Urinary Tract Infections, electrolyte imbalance and dehydration. The findings were: R #1: R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." R #2: R #2's Face Sheet dated 10/25/12 indicated R #2 was admitted to the facility on [DATE]. R #2 was [AGE] years old. R #2's Consolidated physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. R #2 was prescribed a regular diet and fluids, with no fluid restrictions. R #2's Annual Minimum Data Set ((MDS) dated [DATE] indicated R #2 responded adequately to simple, direct communication and was able to make concrete requests. R #2's cognition was moderately impaired (cues and supervision required). R #2 was totally dependent for eating and drinking with assistance from one staff person. R #2's range of motion was impaired on her right and left upper and lower extremities. R #2 was at risk of developing a pressure ulcer. R #2 had received anti-anxiety, antidepressant and diuretics. R #2's Quarterly MDS dated [DATE] indicated R #2 responded adequately to simple, direct communication and was able to make concrete requests. R #2's cognition was moderately impaired (cues and supervision required). R #2 was totally dependent for eating and drinking with assistance from one staff person. R #2's range of motion was impaired on her right and left upper and lower extremities. R #2 was at risk of developing a pressure ulcer. R #2 had received antidepressants and diuretics. R #2's Activities of Daily Living (ADLs, eating, drinking, bathing, grooming, oral hygiene, incontinent care) Care Plan dated 12/16/13 revealed R #2 required total assistance with ADL needs secondary to [MEDICAL CONDITION] and debility (weak/feeble). The goal of the Care Plan was for all of R #2's needs to be met. The approaches to be utilized were for nursing staff to anticipate and assist with all ADL needs. Range of motion provided with ADLs, oral care every morning and after meals, transfer with one staff and monitor R #2 for further decline in ADLs to determine further assistance to meet needs. R #2's Impaired Skin Integrity due to incontinence of bowel and bladder elimination and [DIAGNOSES REDACTED].#2 adequate nutrition and hydration. During observation of R #2's room during initial tour on 02/27/14 at 3:40 p.m. revealed R #2 was lying in her bed. R #2's water pitcher was on a bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. The water pitcher was half full. There was not a drinking glass available. R #2 stated she was thirsty. Observation of R #2's room on 02/27/14 at 6:25 p.m. revealed R #2's water pitcher was on a bedside table located at the foot of R #2's bed. R #2 was sitting up in a wheelchair in the middle of the room. R #2 was approximately three feet from the bedside table and the water. The water pitcher was half full. There was not an available glass next to the water pitcher. Observation and subsequent interview with R #2 on 02/28/14 at 1:30 p.m. revealed R #2 lying in bed. R #2's water pitcher was still on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. The water pitcher was half full. There was not a drinking glass available. R #2 stated she was thirsty. R #2 stated, "I don't have any water, but I want some." Observation of R #2's room on 03/03/14 at 11:40 p.m. revealed R #2's water pitcher was on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. There was an empty plastic glass next to the water pitcher. Observation of R #2 in the dining room on 03/03/14 at 12:35 p.m. revealed R #2 sitting at a dining room table. An unknown staff placed a glass (approximately 6 ounces) of water in front of R #2. R #2 drank 3/4s of the glass of water all at one time. R #2 was given another glass of water with her meal and R #2 drank the entire glass of water during her meal. Observation of R #2's room on 03/03/14 at 4:10 p.m. revealed R #2's water pitcher was on the bedside table located at the foot of R #2's bed, approximately four feet from R #2's bedside. There was an empty plastic glass next to the water pitcher. R #5 R #5's Face Sheet dated 02/28/13 indicated R #5 was admitted to the facility on [DATE]. R #5 was [AGE] years old. R #5's Consolidated physician's orders [REDACTED].#5 [DIAGNOSES REDACTED]. R #5 was prescribed a pureed bland, low fiber diet without any fluid restrictions. R #5's Annual MDS dated [DATE] revealed R #5 was rarely or never understood and rarely or never understood others. R #5 cognition was severely impaired (never/rarely made decisions). R #5 was totally dependent on one staff person for eating and drinking. R #5 had limited range of motion to his left and right lower extremities. R #5 had a stage two pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). R #5 received antidepressants and anti-psychotic medications. R #5's Quarterly MDS dated [DATE] revealed R #5 was rarely or never understood and rarely or never understood others. R #5 cognition was severely impaired. R #5 was totally dependent on one staff person for eating and drinking. R #5 had limited range of motion to his left and right lower extremities. R #5 was at risk of developing pressure ulcers. R #5 received antidepressants and anti-psychotic medications. R #5's ADL Care Plan dated 11/25/13 revealed R #5 had self care deficit due to cognitive deficits due to dementia and required total assistance with ADLs. The goal for R #5 was for R #5 to be well dressed and groomed and comfortable in his environment. The approaches to be utilized by the nursing staff were to explain all procedures before proceeding, assist R #5 with bed mobility every two hours, assist with transfers per two staff and a mechanical lift, assist with dressing, grooming showering, personal hygiene and toileting and encourage activities. Hydration was not listed as an ADL that required assistance by nursing staff. R #5's Care Plan dated 11/25/13 for bowel elimination due to [DIAGNOSES REDACTED].#5 would have a bowel movement every two to three days. The approaches to by utilized by nursing staff were to monitor bowel movements every shift, monitor for abdominal distention, bowel sounds, hard stools or R #5's report of abdominal pressure or fullness, provide adequate nutrition and hydration and report to Physician any unrelieved constipation. During observation and subsequent interview in R #5's room during initial tour on 02/27/14 at 5:00 p.m. with Licensed Vocational Nurse (LVN) "P" present revealed R #5 was lying in his bed. R #5's mouth was open and around his lips was a white dried substance. R #5's water pitcher was next to his bed on a nightstand. There was not a drinking glass available. R #5 stated he was thirsty. LVN "P" stated R #5 had not been eating or drinking because he had diarrhea. LVN "P" did not offer R #5 fluid and continued with the initial tour. During observation and subsequent interview in R #5's room on 02/27/14 at 6:30 p.m. R #5 was being assisted with eating and given fluids by CNA "Q." CNA "Q" stated R #5 ate his food and drank his fluids "good." Surveyor observed R #5 gulp 3/4 of a glass (approximately 6 ounces) of iced tea through a straw. R #5 completed drinking the glass of tea and R #5 drank 1/2 of another glass of iced tea. During observation and subsequent interview with R #5 in the lobby area on the 2nd floor R #5 was observed in his geri-chair (chair used for positioning). R #5's mouth was open and his lips were dry. R #5 said he was "thirsty, for cold water. Ice water." LVN "P" said in an interview on 03/03/14 at 4:01 p.m. she began her shift at 2:00 p.m. and R #5 had not been offered anything to drink since she had arrived at 2:00 p.m. R #7 R #7's Face Sheet (not dated) indicated R #7 was admitted to the facility on [DATE]. R #7 was [AGE] years old. R #7's Consolidated physician's orders [REDACTED].#7 had [DIAGNOSES REDACTED]. R #7 was prescribed a Regular low Concentrated Diet with thin liquids, there were not any fluid restrictions. R #7's Significant Change of Status MDS dated [DATE] indicated R #7 had clear speech, usually understood and was usually understood by others. R #7 required staff assistance with set-up of meal and fluids only and was independent with eating and drinking. R #7's functional range of motion was not impaired on his right or left upper extremities. R #7 had a Urinary Tract Infection within 30 days prior to MDS. R #7 was at risk of developing a pressure ulcer. R #7 had received diuretic and antibiotic medications seven days prior to the assessment. R #7's Care Area Assessment Summary revealed R #7 triggered for dehydration and fluid maintenance. R #7's Readmission/Return MDS dated [DATE] indicated R #7 had clear speech, usually understood and was usually understood by others. R #7 required staff assistance with set-up of meal and fluids only and was independent with eating and drinking. R #7's functional range of motion was impaired on his left lower extremity from a [MEDICAL CONDITION]. R #7 was at risk of developing a pressure ulcer. R #7 had received anti-anxiety, anticoagulant and antibiotic medications seven days prior to the assessment. Review of R #7's UTI Care Plan dated 01/17/14 revealed R #7 was at risk for UTIs due to R #7 had a history of [REDACTED].#7 to have no signs or symptoms of a UTI. The approaches to be utilized by the nursing staff and Certified Nurse Aides (CNAs) were to monitor labs as ordered, encourage fluid intake and monitor for signs and symptoms of UTI. R #7 stated in an interview on 03/03/14 at 2:00 p.m. he was not capable of transferring himself to and from his wheelchair. R #7 stated he was often without water during the day. R #7 said he had asked the CNAs to bring him water and they told him "later" because they were busy. When the day shift filled the water pitcher it was only with water, not fresh ice. R #7 stated the night shift usually filled up the water pitcher with ice and water. On 02/28/14 at 3:20 p.m. CNA "R" stated she worked on Hall 500 and the nurses tell the CNAs who is at risk of dehydration, who to push fluids to and encourage to drink. There is not a list of residents for the CNAs to know who is at risk of dehydration. CNA "R" stated water is passed out to the rooms during every shift and fluids are offered to residents during meals. CNA "R" stated the water pitchers were "supposed to be by the resident's bedside" or the resident would be at risk of dehydration. CNA "R" said residents were at risk of getting dehydrated if they were not able to reach their water. CNA "R" said water was offered to residents every two or three hours but there was not a schedule. CNA "R" stated the CNAs did not write down how much fluids were consumed for residents who were at risk of dehydration. On 02/28/14 at 3:40 p.m. CNA "S" stated she worked on Hall 200. CNA "S" stated the CNAs did not write down the intake of residents who were at risk of dehydration. CNA "S" stated there was not a list of residents who were at risk of dehydration. CNA "S" said, "I feel all residents are at risk for dehydration." CNA "S" said CNAs were to make sure water was at the bedside tables for all residents. CNA "S" said all residents on Hall 200 were able to reach their water. On 02/28/14 at 4:00 p.m. CNA "T" stated she worked on the second floor and CNAs were to offer fluids to residents every two hours. CNA "T" stated she reported to the Charge Nurse if a resident was not drinking. CNA "T" stated residents were at risk of dehydration if they were not able to reach their water. On 02/28/14 at 4:15 p.m. LVN "U" stated she worked on the second floor and there was not a list of residents who were at risk of dehydration for the CNAs to know who was at risk for dehydration. Confidential Interviewee (CI) "ZZ" stated in an interview he/she had been at the facility to visit a family member and the family member was sitting in the dining room at a table. CI "ZZ" said other residents were also present but there were not any staff present. CI "ZZ" said the family member stated he/she was thirsty. CI "ZZ" said he/she got up to get the family member water and other residents began stating they were thirsty. CI "ZZ" said another resident who was capable of walking got up and began passing water out to the residents. CI "ZZ" stated he/she had observed residents sitting in the dining room on several occasions without any fluids available. CI "ZZ" said he/she had observed her/his family member on several occasions without water in the room. The water pitcher may have been in the family member's room but it was out of reach, empty or the water was dirty. CI "ZZ" said the water pitcher was too heavy for the family member to lift. CI "WW" stated in an interview he/she visited his/her family member once or twice a week. CI "WW's" family member's water was always out of reach and the family member was always thirsty when CI "WW" arrived. CI "WW" said the family member would drink an eight ounce glass of water and ask for more. On 03/03/14 at 1:35 p.m. the Director of Nurses (DON) stated in an interview water pitchers were to be within reach of residents. The DON said if residents were in bed the water should be on the bedside table within reach of the resident. Staff were to offer fluids each time a staff person whet into a resident's room, with meals and during supplements. The DON said if a glass was not available for residents to drink, the water pitcher had an opening that allowed residents to drink directly from the water pitcher and a hole for a straw. The DON did not respond when asked what a resident would do if the water pitcher was to heavy to lift. On 03/03/14 at 3:35 p.m. the Administrator stated in an interview water pitchers were to be close enough for residents to reach. The Administrator said if residents did not have a glass available, the resident could drink from a straw or directly out of the water pitcher. The facility's Statement of Resident Rights dated July 2006 indicated, the resident did not give up any rights when they entered the nursing facility. The facility was to encourage and assist resident to fully exercise their rights. The residents had the right to all care necessary for the resident to have the highest possible level of health. The facility's Policy and Procedure for CNA Duties dated March 2012 indicated the day, evening and night shifts were to "make sure residents have fresh water. Encourage fluids for residents unable to take water unassisted." The facility's undated Daily Routine Assignments Per Shift for Nurse Assistants indicated the day, evening and night shifts were to fill "ice pitchers" at the end of each shift. The facility's undated training module Nutrition and Hydration-Your Responsibilities-Fundamentals indicated the facility was required to provide residents with adequate opportunities to maintain an acceptable fluid balance and to prevent hydration. Staff were to offer residents fluids throughout the day, during activities and when care was provided. Residents were to have a fresh pitcher of water available at their besides. Dehydration was preventable by making sure residents were offered fluids throughout the day. Mandatory Monthly In-service to staff dated 11/14/13 revealed the following subjects were covered from 2:00 to 2:30 p.m.: Occupational Safety and Health Cardio [MEDICAL CONDITION] Resuscitation reviewed Pericare covered-Infection control, dignity "Hydration covered-Pitchers" Glucometer cleaning Me

Based on observation, interview, and record review, the facility failed to ensure each resident received and was provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one Resident (R #1) of seven Residents reviewed for neglect. -The facility was aware that R #1 had cloudy, dark brown, foul smelling urine and was dehydrated. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -The facility did not consistently assess or monitor R #1's condition. -The facility did not ensure R #1 received timely and appropriate medical intervention to treat his urinary infection and change in condition. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. These deficient practices placed 43 residents monitored for hydration at risk of not receiving proper assessments, care and services required to prevent delay in treatment, complications or hospitalization . Findings were: R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." The facility's Abuse Policy and Procedure dated 11/2013 revealed: "...It is the policy of this home to prohibit resident abuse or neglect in any form...Definitions (:)...Neglect: The failure to provide goods and services necessary to avoid physical harm..." The facility's Change of Condition Policy dated 03/2012 revealed: "...POLICY It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following:...2. A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; ...PROCEDURE Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline...6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation..." The facility's Intake and Output Measurement Policy and Procedure dated 01/2014 revealed: "...It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs...The Following Residents May Require Measurement and Documentation Of Intake And Output Every Eight Hours, Including a 24-Hour Total And Evaluation: 1. Residents receiving hypodermoclysis (subcutaneous infusion of fluids to treat dehydration) or intravenous feeding during course of treatment...The Nurse may at his/her Discretion Initiate Measurement And Documentation Of Intake And Output Every Eight Hours, Including A 24-Hour Total And Evaluation: 1. Some conditions that may warrant the decision may include, but is not limited to: Diuresis (increased urination), Hydration, Change of Condition..." The facility's undated list of residents at risk of dehydration revealed 43 residents with hydration needs. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to assessments and intervention. As of exit on 03/03/14 at 5:25 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to implement their written policy and procedure that prohibits neglect for one Resident (R #1) of seven Residents reviewed for hydration and urinary tract infections. -The facility was aware that R #1 had cloudy, dark brown, foul smelling urine and was dehydrated. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -The facility did not consistently assess or monitor R #1's condition. -The facility did not ensure R #1 received timely and appropriate medical intervention to treat his urinary infection and change in condition. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. These deficient practices placed 43 residents monitored for hydration at risk of not receiving proper assessments, care and services required to prevent delay in treatment, complications or hospitalization . Findings were: The facility's Abuse Policy and Procedure dated 11/2013 revealed: "...It is the policy of this home to prohibit resident abuse or neglect in any form...Definitions (:)...Neglect: The failure to provide goods and services necessary to avoid physical harm..." The facility's Change of Condition Policy dated 03/2012 revealed: "...POLICY It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following:...2. A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; ...PROCEDURE Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline...6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation..." The facility's Intake and Output Measurement Policy and Procedure dated 01/2014 revealed: "...It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs...The Following Residents May Require Measurement and Documentation Of Intake And Output Every Eight Hours, Including a 24-Hour Total And Evaluation: 1. Residents receiving hypodermoclysis (subcutaneous infusion of fluids to treat dehydration) or intravenous feeding during course of treatment...The Nurse may at his/her Discretion Initiate Measurement And Documentation Of Intake And Output Every Eight Hours, Including A 24-Hour Total And Evaluation: 1. Some conditions that may warrant the decision may include, but is not limited to: Diuresis (increased urination), Hydration, Change of Condition..." R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." The facility's undated list of residents at risk of dehydration revealed 43 residents with hydration needs. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to neglect. As of exit on 03/03/14 at 5:25 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #1) of seven Residents reviewed for hydration and urinary tract infections. -The facility was aware that R #1 had cloudy, dark brown, foul smelling urine and was dehydrated. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -The facility did not consistently assess or monitor R #1's condition. -The facility did not ensure R #1 received timely and appropriate medical intervention to treat his urinary infection and change in condition. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. These deficient practices placed 43 residents monitored for hydration at risk of not receiving proper assessments, care and services required to prevent delay in treatment, complications or hospitalization . Findings were: R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." The facility's Abuse Policy and Procedure dated 11/2013 revealed: "...It is the policy of this home to prohibit resident abuse or neglect in any form...Definitions (:)...Neglect: The failure to provide goods and services necessary to avoid physical harm..." The facility's Change of Condition Policy dated 03/2012 revealed: "...POLICY It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following:...2. A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; ...PROCEDURE Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline...6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation..." The facility's Intake and Output Measurement Policy and Procedure dated 01/2014 revealed: "...It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs...The Following Residents May Require Measurement and Documentation Of Intake And Output Every Eight Hours, Including a 24-Hour Total And Evaluation: 1. Residents receiving hypodermoclysis (subcutaneous infusion of fluids to treat dehydration) or intravenous feeding during course of treatment...The Nurse may at his/her Discretion Initiate Measurement And Documentation Of Intake And Output Every Eight Hours, Including A 24-Hour Total And Evaluation: 1. Some conditions that may warrant the decision may include, but is not limited to: Diuresis (increased urination), Hydration, Change of Condition..." The facility's undated list of residents at risk of dehydration revealed 43 residents with hydration needs. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to neglect. As of exit on 03/03/14 at 5:25 p.m., the facility provided no further information.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's mental status and laboratory results for one Resident (R #1) of seven Residents reviewed for hydration and urinary tract infections. -R #1 was at risk for urinary tract infections and dehydration due to his diagnoses. -The facility did not confirm receipt of R #1's urinalysis result or consult with R #1's Physician, which delayed Physician's involvement or intervention. -R #1 was sent to the hospital two days later [MEDICAL CONDITION], dehydration and cloudy, green colored urine. -R #1 was admitted to hospice after discharge from the hospital. These deficient practices placed 43 residents monitored for hydration at risk of not receiving proper assessments, care and services required to prevent delay in treatment, complications or hospitalization . Findings were: R #1's undated Face Sheet revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Significant Change MDS dated [DATE] revealed R #1 usually understood others and usually made self understood; had moderately impaired cognition (decisions poor; cues/supervision required); was independent with locomotion in unit; was totally dependent on staff for toilet use, bed mobility and transfers; was independent with eating; was always incontinent of bowel and bladder; did not have a swallowing disorder; and did not have a life expectancy of less than six months. R #1's laboratory results dated [DATE] revealed R #1's urea nitrogen, creatinine, estimated glomerular filtration rate, chloride, glucose and white blood cells were normal. R #1's Nurses Notes revealed the following handwritten and dated entries: -01/27/14 at 1:25 p.m.: R #1 was noted to have weight loss; the physician and family were notified; new orders were received. There was no other documentation of R #1's condition. -There were no other entries from 01/27/14 through 02/16/14, approximately 20 days. -02/17/14 at 2:00 p.m.: R #1 was noted to have decreased alertness and decreased appetite. There was no other documentation of R #1's condition. -02/17/14 at 8:00 p.m.: R #1 was "(orally) pocketing food." The physician was notified and an order for [REDACTED]. -02/18/14 at 1:45 a.m.: BP 114/78, T 97.6, P 74, R 18. "...F/U pocketing food. Fluids taken very small amount during night. Will monitor." -There were no other entries from 02/18/13 through 02/19/14 at 12:15 a.m. -02/19/14 at 12:15 a.m., 22 hours after the last entry: R #1's urine was collected for urinalysis. "...Urine cloudy dark brown (with) foul odor. PO fluids given. Will monitor." -02/19/14 at 2:00 a.m.: BP 152/72, T 97.8, P 78, R 18. "PO fluids encouraged. Will monitor." R #1's Physician's Telephone Order dated 02/18/14 revealed an order to obtain CMP, CBC and UA with C&S on 02/19/14. R #1's CMP "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 12:00 PM" revealed: -Urea Nitrogen 106, "panic value" -Creatinine 2.9, "high" -Estimated Glomerular Filtration Rate 21, "low" -Chloride 106, normal -Glucose 94, normal. -"Faxed 2/19/14" with illegible initials were handwritten on the bottom right corner of the result. According to www.labtestsonline.org on 03/14/14, R #1's CMP result dated 02/19/14 indicated that R #1 had the potential to be dehydrated and the potential to have kidney failure. Continuing with the Nurses Notes: -02/19/14 at 11:55 a.m.: "RP + MD made aware of lab results (CMP). Awaiting for call back from MD..." The handwritten entry revealed R #1 was up in a wheelchair, had a "decreased appetite", was "lethargic" and had "decreased alertness." There were no vital signs or other assessments documented. On 02/27/14 at 2:45 p.m. Family Member (FM) "XX" stated in an interview, two to three weeks ago R #1 was in a wheelchair and communicating. FM "YY" said around 02/10/14 she and FM "YY" had "noticed" R #1 was not eating or talking as he had been. R #1 was thirsty. The facility stated a "virus" had been going around the facility. FM "YY" requested R #1 to be assessed by a doctor. The facility nurse stated the facility was going to "run test". R #1's FM "YY" visited R #1 at the facility on 02/20/14. R #1 was receiving an IV for dehydration. An unknown facility staff told FM "YY" R #1 "may have a possible UTI." FM "YY" requested R #1 to be sent to the hospital. The unknown facility staff told FM "YY" R #1 was receiving IV fluids and the facility was waiting for the doctor to contact the facility. FM "XX" told the nurse R #1 was not receiving antibiotics with the IV. The nurse told FM "XX" the facility was going to consult with the doctor. R #1's "Bacteria PCR, Urine" lab result "Collected: 02/19/2014 06:27 AM" revealed: -"Source - Urine" -"Final Report: (8:46 p.m.) 19 [DATE]" -"Positive" -"Bacterial infection detected..." R #1's CBC "Collected: 02/19/2014 06:22 AM Resulted: 02/20/2014 01:33 AM" revealed R #1's white blood cells were 15.3, "high" (an indication of infection). R #1's UA "Collected: 02/19/2014 06:22 AM Resulted: 02/19/2014 10:24 PM" revealed a fax date/time stamp that MD "A" was faxed on 02/20/14 at 1:42 a.m. of the following result: -Color "brown" -Clarity "opaque" -Red blood cells "10-20", high -White blood cells "(high)" -Bacteria "large." According to www.labtestsonline.org on 03/14/14, R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14 indicated that R #1 had the potential to have a urinary tract infection. Continuing with the nurses notes: -02/19/14 at 10:30 p.m.: "N.O (for)...NS...x 2 days. IV to rt forearm infusing; pt tolerating IV well (fluids); shall continue to monitor." -02/19/14 at 11:00 p.m.: "...NS...infusing well. PO fluids given (illegible) 50 cc (1.69 ounces). Will monitor." -02/20/14 at 1:15 a.m.: BP 102/56, T 97.4, P 62, R 16. "Opens eyes when spoken to. Ref. PO fluids. IV infusing well. Will monitor." -02/20/14: 2:30 a.m.: "Took 30 cc (1.01 ounces) of liq. Will monitor." -02/20/14 at 5:30 a.m.: "Took 150 cc (5.07 ounces) of liq. Peripheral line patent (and infusing) well." -02/20/14 at 10:00 p.m., approximately 16 hours after the last entry: "Cont on F/U for dehydration. IV...infusing well. IV site (without) s/s of infection/infiltration. s/s of (increased) restlessness and discomfort. PRN [MEDICATION NAME]/[MEDICATION NAME] (antianxiety/pain medications) admin. Res tolerated minimum amount of water and dinner. Will cont. to monitor." There was no indication in the Nurses Notes that the facility consulted with R #1's Physician regarding the UA, Bacteria PCR and CBC lab results dated 02/19/14. On 02/27/14 at 2:45 p.m. FM "XX" stated the facility called FM "XX" on 02/21/14 at 3:00 p.m. and notified FM "XX" and FM "YY" R #1 had a high fever, low blood pressure and dehydration. FM "YY" told the facility to send R #1 to the hospital. FM "YY" was told by the staff the facility was waiting for the doctor to contact the facility for a transfer order. FM "YY" told the staff to send R #2 to the hospital and not to wait on the doctor. FM "XX" said R #1 arrived at Hospital "AA" at 4:30 p.m. on 02/21/14. An hour and a half after the facility notified FM "XX" and FM "WW" R #1 was not doing good. FM "XX" said R #1 was non- responsive when he was admitted to the hospital with [REDACTED]. R #1 was diagnosed with [REDACTED].#1's penis to get the urine. FM "XX" said as of 02/27/14 R #1 continued to be in the hospital and FM "XX" and FM "YY" had contacted Hospice. Continuing with the Nurses Notes: -02/21/14 at 1:00 a.m.: "HOB (elevated) resting well, skin W/D, eyes open, non-verbal (illegible) IV infusing well per regulator..." T 98.4, P 82, R 20, BP 134/70. "...breath sounds clear, lungs clear, abd. soft, incont of urine. IV site (without) redness or swelling...Will cont to monitor..." -02/21/14 at 6:00 a.m.: "IV cont to infuse well, HOB (elevated)." -02/21/14 at 12:00 p.m.: "Rec'd fax from (MD "A") office, N.O. STAT CMP (and) CBC to be faxed back to MD office ASAP, lab notified, await their arrival for blood draw, res. resting comfortably. IV cont. to flow, (no) s/s of infiltrate (IV fluid in the surrounding tissue, instead of in the vein), safety maintained, will cont to monitor." -02/21/14 at 3:00 p.m.: "Spoke (with) RP reg. (change) in res. condition, states send him to hospital, call out to (MD "A") x 3 detailed messages left..." BP 75/46, P 88, R 38, T 100.6. ..."unresponsive, PRN [MEDICATION NAME] adm. Await (transport to hospital)." -02/21/14 at 3:30 p.m.: "IV dc'd., pt. prepared for transport..." BP 95/45, T 101, P 100, R 16. "...telephoned (Hospital "AA") endorsed aforementioned..." At 4:10 p.m., R #1 was transported to Hospital "AA", over 40 hours after the facility received R #1's Bacteria PCR, Urine, UA and CBC results dated 02/19/14. R #1's Comprehensive Metabolic Profile "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:37 PM" revealed: -Urea Nitrogen 123, "panic value" -Creatinine 2.8, "high" -Estimated Glomerular Filtration Rate 22, "low" -Chloride 111, "high" -Glucose 120, "high." R #1's Complete Blood Count "Collected: 02/21/2014 01:36 AM Resulted: 02/21/2014 3:09 PM" revealed: -White blood cells 15.9, "high." R #1's clinical records dated 02/21/14 from Hospital "AA" revealed: Urinalysis: -Color "green" -Clarity "turbid" (clouded or obscured, as in solids in suspension in a solution) -Red blood cells 20-30, "high" -White blood cells 20-30, "high." Comprehensive Metabolic Profile: -Sodium 150, "high" -Chloride 113, "high" -Glucose 125, "high" -Blood urea nitrogen 144, "high" -Creatinine 3.2, "high" -Estimated Glomerular Filtration Rate 20, "low" Complete Blood Count: -White blood cells 19.1, "high" History and Physical dated 02/26/14 revealed R #1: -Had a Glasgow coma scale of "3" (no eye opening, no verbal and no motor response) on 02/21/14; -Had the [DIAGNOSES REDACTED]. *Sepsis (blood infection) *Altered Mental Status *UTI *[MEDICAL CONDITION] (high sodium), "likely secondary to dehydration" *Acute [MEDICAL CONDITION] "on" [MEDICAL CONDITION] Stage IV, "this is most likely secondary to dehydration" *End Stage [MEDICAL CONDITION] that was "most likely secondary to acute [MEDICAL CONDITION]." According to www.sepsisalliance.org on 03/14/14, "Sepsis is a toxic response to infection that kills 258,000 Americans each year. It is a medical emergency that requires early detection and treatment for [REDACTED]. According to www.mayoclinic.org on 03/14/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." R #1's "Clinical Note" dated 02/27/14 from Hospital "AA" revealed: "...Discussion had with the family regarding hospice and comfort care....Patient will be discharged to...hospice today." R #1's History and Physical from Hospice "BB" dated 02/27/14 revealed R #1 was admitted to Hospice "BB" on 02/27/14. R #1's physician progress notes [REDACTED]. -History Present Illness: "Non-responsive...sepsis probably from UTI...poor prognosis." On 03/03/14 at 10:45 a.m. at Hospice "BB", R #1 was lying bed, no signs or symptoms of distress and was able to drink fluids. R #1 had an indwelling urinary catheter (a hollow flexible tube inserted into the bladder to aide in urination) with clear yellow urine. R #1 did not respond to surveyor's questions. On 03/03/14 at 3:50 p.m., R #1's MD "A" stated that R #1 received IV fluids instead of being sent to the hospital for his abnormal labs on 02/19/14. MD "A" stated that he "did not see the (urinalysis) result" for R #1 dated 02/19/14 and faxed to MD "A" on 02/20/14. MD "A" stated that the facility "would call (MD "A") with lab results for an emergency." Surveyor asked MD "A" if R #1's urinalysis would warrant a phone call instead of a fax. MD "A" stated, "Yes." MD "A" stated, "Normally I would give an antibiotic before a culture and sensitivity was back if (the urinalysis) was like (R #1's)." On 02/28/14 at 4:15 p.m., LVN "U" stated it was the facility's policy to fax labs to resident's physicians to notify the physician of the lab result. LVN "U" stated nurses were responsible to "follow-up with labs." On 03/03/14 at 12:20 p.m., LVN "B" stated that it was the facility's policy to document intake and output for residents when "there was a physician order." LVN "B" stated that nurses were responsible for lab follow-up." LVN "B" stated she was in charge of R #1 on 02/19/14 on the 7:00 a.m. to 3:00 p.m. shift. LVN "B" stated it was the facility's policy to fax lab results to the physician and to call the physician with lab results if there were "panic values." LVN "B" stated that she called MD "A's" office on 02/19/14 with R #1's Comprehensive Metabolic Profile "panic values" dated 02/19/14 and that "a doctor" ordered IV fluids for R #1 instead of sending R #1 to the hospital. LVN "B" stated R #1's urinalysis was not completed by the lab company at the time of her phone call to MD "A's" office. LVN "B" stated she would "call the doctor instead of faxing" to alert MD "A" of R #1's urinalysis to "get an antibiotic" because "sepsis could result." LVN "B" stated she was not aware of R #1's urinalysis result dated 02/19/14. LVN "B" stated that on 02/21/14 R #1 had a "change in condition" and she notified R #1's RP. LVN "B" stated that R #1's RP requested R #1 be sent to the hospital and LVN "B" notified MD "A" of the RP's request. LVN "B" stated R #1 was sent to the hospital on [DATE]. On 03/03/14 at 12:40 p.m., ADON "C" stated it was the facility's policy to document intake and output for residents when "the physician ordered it." ADON "C" stated it was the facility's policy to discuss resident's lab results during the daily morning meetings to ensure labs were followed up on. ADON "C" stated that after the nurses received a lab result, the nurses would fax it to the physician and "either they put it in my box or on the 24 hour report." ADON "C" stated that R #1 received IV fluids instead of being sent to the hospital on [DATE]. ADON "C" stated she "wasn't aware of (R #1's urinalysis) result. The doctor should've been called. The UA was missed. I don't know why it was missed." ADON "C" stated R #1 "could be septic." On 03/03/14 at 1:25 p.m., the DON stated that R #1's Physician was aware of R #1's urinalysis results dated 02/19/14 because "the UA was faxed to the doctor." When asked how the facility knew the physician received and viewed R #1's urinalysis dated 02/19/14, the DON stated, "The doctor gets up every day at 4:00 a.m. and reads his labs at 4:00 a.m. That is the procedure." The facility's Change of Condition Policy dated 03/2012 revealed: "...POLICY It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following:...2. A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; ...PROCEDURE Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline...6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation..." The facility's Intake and Output Measurement Policy and Procedure dated 01/2014 revealed: "...It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs...The Following Residents May Require Measurement and Documentation Of Intake And Output Every Eight Hours, Including a 24-Hour Total And Evaluation: 1. Residents receiving hypodermoclysis (subcutaneous infusion of fluids to treat dehydration) or intravenous feeding during course of treatment...The Nurse may at his/her Discretion Initiate Measurement And Documentation Of Intake And Output Every Eight Hours, Including A 24-Hour Total And Evaluation: 1. Some conditions that may warrant the decision may include, but is not limited to: Diuresis (increased urination), Hydration, Change of Condition..." The facility's undated list of residents at risk of dehydration revealed 43 residents with hydration needs. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to notification of changes. As of exit on 03/03/14 at 5:25 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to ensure one resident R#2 out of two residents reviewed received the necessary treatment and services to prevent new sores from developing. The facility failed to remove the immobilizer and assess R#2's skin. This failure could affect two residents in the facility with immobilizers. Findings included: According to Taber's CYCLOPEDIC MEDICAL DICTIONARY, Edition 21 pages 1154, the definition of an immobilizer is a device to fix the position of a joint or fractured limb, as with a splint or cast, to impede movement. Review of R#2's Face Sheet dated 02/28/13 revealed a [AGE] year old female admitted to the facility on [DATE], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R#2's Change in Condition Minimum (MDS) data set [DATE] revealed the facility had identified the following: --rarely/never understood or understands --severly impaired cognitive skills for daily decision making --total dependence for dressing, eating, transfer, and personal hygiene --impairment to both lower extremities (hip, knee, ankle, foot) --at risk for developing pressure ulcers --two unstageable pressure ulcers that were present upon admission/reentry to the facility Review of R#2's care plans updated 03/08/13 revealed: -- fracture to right tibia (the inner and larger bone of the leg between the knee and the ankle), immobilizer to right leg, "staff in serviced on reporting swelling, bruising, etc." -- at risk for impaired skin integrity and slow healing related to [DIAGNOSES REDACTED]. --"resident will maintain current skin integrity through the next review date" --monitor skin integrity every shift --notify the physician of any noted skin integrity problems Review of the facility document entitled "Primary Risk Factors for Pressure Ulcer Development" dated 02/26/13 for R#2 revealed: cognition, impaired mobility, and decreased functional ability, impaired sensation, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the Physician order [REDACTED].#2 revealed "Apply brace to right ankle" Review of the facility head - toe weekly skin assessment for R#2 revealed the following finding: --by LVN/Treatment Nurse "M" dated 03/10/13 for R#2 revealed no skin problems, bruise to right lower leg. --by LVN "P" dated 03/17/13 redness to buttock bi-laterally During an interview on 03/22/13 at 2:15 p.m. the LVN/Treatment Nurse "M" stated the last skin assessment she performed on R#3 dated 03/10/13, she did remove the immobilizer to R#2's right leg and identified the bruising from the fracture on 03/07/13, but no pressure sores. Observation on 03/13/13 at 10:15 a.m. of R#2's right leg revealed greenish/yellowish bruising below the outer aspect of the right leg below the knee, a dark purplish color bruising on the outer aspect of the calf, and a dark purple bruising approximately a quarter in size on the bony prominence of R#2's right ankle bone. The immobilizer was removed by Licensed Vocational Nurse (LVN) "C" for observation. Review of a late entry written by RN "A" on 03/13/13 at 9:00 p.m. on R#2's clinical records revealed "notified by CNA that ( R#2) (right) leg was bothering her. Assessed her leg. compared to (left) leg. No injury noted. Noted some discoloration but not bruising. Read her chart and noted arthritis." Review of the nurse note dated 03/18/13, no time by LVN "L" for R#2 revealed "(Right) leg immobilizer intact (without) [MEDICAL CONDITION], errythema, or (sign or symptoms) of discomfort. After removing straps of (Right) leg immobilizer , no apparent pressure wounds to (Right) Leg." During an interview, and review of nurse note dated 03/18/13 by LVN L" on 03/22/13 at 3:05 p.m. LVN "L" stated she had not removed the immobilizer and inspected the skin of R#2's right leg. LVN "L" said she "just undid the straps and assessed the foot." During an interview on 03/21/13 at 2:40 p.m. LVN "K" stated LVN/Treatment Nurse "M" accompanied R#2 to the orthopedic physician appointment on 03/21/13, and three wounds were observed on R#2's right lower leg when the immobilizer was removed by the physician. LVN "K" stated she had never removed the immobilizer to R#2 right leg to assess the skin when she was assigned R#2. LVN "K"said she would just remove the top straps and assess the top of the leg. Observation on 03/21/13 at 2:41 p.m. of R#2's right leg with LVN "K" revealed; 1) On R#2's outer part of her big toe a dark area scabbed over with light pink edges approximately the size of a quarter 2) On R#2's right heel a dime size dark purple area 3) On R#2's right outter ankle bony prominence a dark area approximately the size of a quarter with light pinkish colored outer edges During an interview on 03/21/13 at 3:45 p.m. LVN/Treatment Nurse "M" stated she had accompanied R#2 to the orthopedic physician's appointment on 03/21/13 and when the physician removed the immobilizer the three "pressure ulcers" were observed by the physician. LVN/Treatment Nurse "M" stated she reported the findings to LVN "K" upon returning to the facility on [DATE]. LVN /Treatment Nurse "M" said the pressure ulcer to R#2 right leg could have been caused the immobilizer "the padding is hard and she (R#2) is very boney." LVN/Treatment Nurse "M" added the pressure sores could have been avoidable, by removing the immobilizer and leaving off for a while. LVN/Treatment Nurse "M" said on the weekly skin assessment for R#2 she completed on 03/10/13 revealed no pressure ulcers, only the bruising to R#2's right lower leg, and she had removed the immobilizer to inspect the skin. During an interview on 03/21/13 at 4:30 p.m. the Director of Nurses ( DON) stated the facility did not have a policy or procedure on immobilizer usage, and every resident was assigned a nurse to do a complete head-toe skin assessment on a weekly basis. The DON could not find any documentation for R#2 by the nursing staff of the skin under the immobilizer on R#2 being assessed from 03/17/13 to 03/21/13. She stated the head to toe skin assessment done by LVN "P" on 03/17/13 should have included the bruising to R#2's right leg, and the immobilizer should have been removed and skin inspected. Review of a communication sheet between the facility and physician entitled "Telephone Encounter" dated 03/21/13 at 2:15 p.m. revealed R#2 "has a Stage 2 to her heel (and) unstageable to ankle (and) feet. Need wound care." According to www. medical-directory on line site 04/05/13. Stage 2 is characterized by blistering, cracking, or abrasion of the skin. Since there is now an opening in the skin for the entrance of bacteria, treatment must include cleaning the wound and providing some type of dressing or cover in addition to relieving pressure on the area. According to www.medscape.com/view article/ 3_8 internet site referenced and printed 03/26/13 an UTD is defined as an unstageable tissue depth, (until enough slough and/or eschar (dead matter that is cast off from the surface of the skin) is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined). Review of LVN/Treatment Nurse "M" note dated 03/21/13 at 3:50 p.m. revealed the following for R#2 1) Right"malleolus" (the bony prominence on each side of the ankle) measuring 3.0 centimeters (cm) by 1.0 cm identified by LVN "M" as an UTD 2) Right "hallux" (the great toe) measured 2.0 cm by 2.0 cm as an UTD 3) Right "heel" measured 2.0 cm by 5.0 cm by 0.2 cm During an interview on 03/22/13 at 2:15 p.m. LVN/Treatment Nurse "M" said her note for R#2 right leg documentation dated 03/21/13 at 3:50 p.m. measurements were "pressure ulcers", and the measurements were in cm's. During an interview on 03/22/13 at 8:40 a.m. the Assistant Director of Nurses (ADON) "A" stated when an order for [REDACTED]. to ask physical therapy." ADON "A" stated the immobilizer for R#2 was no longer in her room it was at the nurse's station. Observation on 03/22/13 at 8:37 a.m. of R#2's immobilizer boot located at the nurse station revealed the name of another resident and room number. During an interview on 03/22/13 at 9:30 a.m. Physical Therapy Assistant (PTA) /Director "O" stated she had asked the supplier to fax the instructions for use of the immobilizer issued to R#2. PTA/Director "O" stated she did not have a copy, pamphlet, or instructions on usage in the facility, and did not keep a binder with the manufacture's recommendation on equipment useage. PTA "O" stated when the order was written by a physician for a splint or immobilizer it was given to them by the nursing department and the PT department would obtain the equipment for the resident. PTA/Director "O" said she did not know the immobilizer for R#2 was used, but it was not uncommon to re-use equipment after it was inspected and cleaned. PTA/Director "O" said she had never been asked by the nursing staff to explain or demonstrate the usage of equipment, and that was a good question. Review of the manufacturer's immobilizer boot used for R#2 manufacture instructions printed off the internet by the DON on 03/22/13 at 10:15 a.m. revealed; "Cautions/Warnings, READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE USING THE DEVICE" --"Caution should be used if prescribed for patients with diabetes, vascular deficiency, and [MEDICAL CONDITION]" --"The skin should be checked regularly" --"Ensure patient performs circulation checks, if discomfort, the patent should contact their medical professional immediately" --"This device should not be applied on patients who are not able to communicate discomfort" Review of the facility document entitled " Policy and Procedure, Skin Integrity Monitoring System, REVISED DATE 03/2012" revealed: Under "Policy" "It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed and preventive measures will be in place to prevent the development of pressure ulcers. 3. A system will be in place to assure any type of skin condition that do not constitute pressure ulcers, will be monitored closely for any type of complications." Under "Procedure 3. All residents will assessed weekly using the (Weekly Skin Assessment) from for any type of skin integrity complications; this will include pressure ulcers and non-pressure ulcer related complications." Under "Definitions, Pressure Ulcer--localized injury to the skin and/or underlying tissue. Pressure ulcers usually occur over a bony prominence as a result of pressure, or pressure in combination with shear/and or friction." During an interview on 03/22/13 at 2:45 p.m. via telephone LVN "R" stated worked 03/20/13 the 10:00 p.m. to 6:00 a.m. shift and she did not remove the immobilizer and inspect the skin. LVN "R" said and was not told in report by LVN "P" R#2 had immobilizer to the right leg. During an interview on 03/22/13 at 4:20 p.m. LVN "P" stated on 03/17/13 he completed a weekly head to toe skin assessment on R#2. LVN "P" said he had not removed the immobilizer to assess the skin to right leg on 03/17/13 or any of the other days he was assigned R#2 since the immobilizer was placed. LVN "P" said he was not aware of the manufacture instructions for the immobilzer placed on R#2. Review of the facility schedule of nursing staff from 03/17/13 on the 3-11 p.m. shift ( and last head to toe skin assessment documented by LVN "P") to 03/21/13 on the 7:00 a.m. to 3:00 p.m. shift revealed a total of 11 shifts, over three days and eight different nurses assigned to R#2. Four out of eight nurses interviewed stated they had never completely removed the immobilizer and inspected R#2's right leg skin. According to Taber's CYCLOPEDIC MEDICAL DICTIONARY, Edition 21 page 1155 "The healthcare professional should ensure that blood supply to the extremities is not restricted by any appliance. Limbs should be evaluated regularly for distal neurovascular states, noting changes in size, color, temperature or pain of the limbs." According to an interview on 03/22/13 the ADON "A" stated two residents in the facility had immobilizers. During the exit conference on 03/22/13 at 5:00 p.m. the facility was given an opportunity to provide additional information, none was provided.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures that prohibit neglect for two Residents (R #1, R #2) of ten Residents reviewed for neglect. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to implement aspiration precautions and ensure staff knew what those precautions were to protect R #1 and R #2 from potentially developing aspiration pneumonia, [MEDICAL CONDITION] and/or death affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech Therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". The facility's Abuse Policy and Procedure dated ,[DATE] revealed:..."It is the policy of this home to prohibit abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on observation, interview, and record review, the facility failed to implement their written policy and procedures that prohibit neglect for two Residents (R #1, R #2) of ten Residents reviewed for neglect. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to implement aspiration precautions and ensure staff knew what those precautions were to protect R #1 and R #2 from potentially developing aspiration pneumonia, [MEDICAL CONDITION] and/or death affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: The facility's Abuse Policy and Procedure dated ,[DATE] revealed:..."It is the policy of this home to prohibit abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech Therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on observation, interview, and record review, the facility failed to use the results of the comprehensive resident assessment to develop a comprehensive care plan to include measurable objectives and timetables for two Residents (R #1, R #2) of ten Residents reviewed for care plans. Resident #1 and Resident #2 were assessed and determined to be at risk for aspiration, but these risks were not addressed in the comprehensive care plan. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to address aspiration risks for residents in the comprehensive care plan affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech Therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on observaton, interview and record review, the facility failed to ensure services provided met professional standards of quality for two Residents (R #1, R #2) of ten Residents reviewed for quality of care. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to implement aspiration precautions and ensure staff knew what those precautions were to protect R #1 and R #2 from potentially developing aspiration pneumonia, [MEDICAL CONDITION] and/or death affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: The American Speech-Language-Hearing Association, http://www.asha.org/policy/PP,[DATE]/#sec1.2.6, states..."Speech-language pathologists prepare, sign, and maintain, within an established time frame, documentation that reflects the nature of the professional service. Results of assessment and treatment are reported to the patient/client and family/caregivers, as appropriate. Reports are distributed to the referral source and other professionals when appropriate...Except for screenings, documentation addresses the type and severity of the communication or related disorder or difference, associated conditions (e.g., medical or educational diagnoses) and impact on activity and participation (e.g., educational, vocational, social)..." R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech Therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for two Residents (R #1, R #2 ) of ten Residents reviewed for aspiration precautions. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to implement aspiration precautions and ensure staff knew what those precautions were to protect R #1 and R #2 from potentially developing aspiration pneumonia, [MEDICAL CONDITION] and/or death affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech Therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for two Residents (R #1, R #2) of ten Residents reviewed for neglect and quality of care. The Administrator failed to: 1) Supervise the Speech Therapist (ST) to ensure he followed the facility's neglect policy. The ST was aware that R #1 and R #2 were at risk of aspiration but failed to implement aspiration precautions. 2) Supervise the Director Of Nurses (DON) to ensure she followed the facility's neglect policy. The DON was aware that R #1 and R #2 were at risk of aspiration but failed to ensure aspiration precautions were in place to protect R #1 and R #2. The DON failed to: 1) Put preventative measures in place when she became aware that R #1 and R #2 were at risk of neglect and aspiration. 2) Implement policies and procedures regarding aspiration precautions. 3) Supervise the nursing staff to ensure that the nursing staff were trained regarding aspiration precautions. -The facility knew R #1 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #1. -Staff were not aware of all of the aspiration precautions to protect R #1 from potential harm. -Staff gave R #1 thickened liquids with a straw and left R #1 alone in his room with the thickened liquid and straw so R #1 could get a drink on his own with the head of his bed at an approximate 45 degree angle, rather than a 90 degree angle. -The facility sent R #1 to the hospital with a fever, a rapid pulse, and signs and symptoms of aspiration. -R #1 died 14 days later. -The facility knew R #2 was at risk for aspiration. -The facility did not inservice staff on aspiration precautions. -The Speech Therapist did not communicate to staff or the physician the Modified [MEDICATION NAME] Swallow diet and aspiration precaution recommendations for R #2. -Staff were not aware of all of the aspiration precautions to protect R #2 from potential harm. -Staff left thickened liquid with a straw in the resident's room. -LVN "D" gave R #2 thickened liquids with a straw. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to implement aspiration precautions and ensure staff knew what those precautions were to protect R #1 and R #2 from potentially developing aspiration pneumonia, [MEDICAL CONDITION] and/or death affected R #1 and R #2 by possibly denying them care and services to avoid physical harm and could place 26 residents with aspiration precautions at risk for lack of services. Findings were: R #1 R #1's facility Radiology Report dated [DATE], five days before R #1 was sent to the hospital on [DATE], revealed "No pneumonia" and that R #1 had a normal chest x-ray. R #1's Nurses Notes dated [DATE] revealed the following: "10:15 (no a.m. or p.m.): 102.0 (temperature). Wheezing (both lungs) noted (with) crackles (bubbling noises) expiratory (on exhale). Medicated (with [MEDICATION NAME]) 650 (milligrams by mouth). (Chest x-ray) per protocol ordered...(Oxygen saturation) 79% (on room air) (respirations) 30. (3 liters nasal cannula) 80%. (Blood pressure) ,[DATE], (pulse) 134 (irregular). Responds to verbal stimuli. 10:30 (no a.m. or p.m.): Received order per (physician) to send to (hospital)...11:45 (no a.m. or p.m.) Transferred to (hospital)..." R #1's Hospital Chest X-Ray dated [DATE] revealed fluid present in both lungs. R #1's Hospital Clinical Records revealed on [DATE], R #1 was transferred to a hospice facility. R #1's Hospice Clinical Records revealed: -[DATE]:..."(R #1) had aspiration pneumonia...when admitted to the hospital..." -[DATE] at 8:50 p.m.:..."(R #1) has no apical heart rate, no respirations, passed peacefully..." According to http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm on [DATE], symptoms of aspiration pneumonia include:..."Fever, shortness of breath, and wheezing... crackling sounds in the lungs, decreased oxygen and rapid pulse..." R #1's Face Sheet dated [DATE] revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Reflux. R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 coughed or choked during meals or when swallowing medications; had a mechanically altered and therapeutic diet; slurred or mumbled words; responded adequately to simple, direct communication only; had severely impaired cognition (never/rarely made decisions); had an altered level of consciousness and inattention that did not fluctuate; was totally dependent on staff for eating and personal hygiene. R #1's Speech Therapy Plan of Care dated [DATE] and [DATE] revealed:..."at risk for aspiration." The Care Plan dated [DATE] revealed:..."choking reported by caregivers..." The Care Plan dated [DATE] did not include the recommendations from the MBSS dated [DATE]. R #1's Speech Therapist Progress notes dated [DATE] and [DATE] revealed:..."at risk for aspiration." R #1's Physician order [REDACTED]. -On [DATE], thicken liquids to honey consistency until MBSS (modified [MEDICATION NAME] swallow study) is done. -On [DATE], pureed (diet)...thin liquids, thicken to honey consistency until MBSS done. -On [DATE], Speech Therapy three times per week for four weeks to improve swallow due to dysphagia. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8,..."(The) Rationale for performing (videofluoroscopic swallowing studies) VFSS (MBSS): -To identify normal and abnormal anatomy and physiology of the swallow. -To evaluate integrity of airway protection before, during, and after swallowing. -To evaluate the effectiveness of postures, maneuvers, [MEDICATION NAME] modifications, and sensory enhancements in improving swallowing safety and efficiency. -To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions). -To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. -To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency..." R #1's MBSS results dated [DATE] revealed the following: -Risk of aspiration was high due to decreased oral control. -Diet: Pureed, alternate bites/sips; double swallow every one to two [MEDICATION NAME] (food/fluid); Nectar thick liquids, small controlled "cup sips" (small sips) with nectar; trial feedings (with Speech Therapist) of thin (liquids) via small controlled straw sips using chin tuck. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow, crush meds, patient to be fed,"positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 10:00 a.m., the Speech therapist (ST) stated aspiration precautions included, "Double swallows, throat clearing, and sitting upright" and supervised feeding meant residents ate meals in the dining room with staff present to monitor the residents. On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that it was his responsibility to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use or swallowing and feeding techniques for R #1 and that he (ST) should have. The ST stated that he "would not approve" of staff providing R #1 a straw to drink and that R #1 was to be at a 90 degree angle at all times because he was at risk of aspiration. The ST stated he inserviced the nurses in the hallway of the facility in [DATE] to inform them that R #1 was required to sit at a 90 degree angle at all times, including while in bed. The ST stated he did not give the staff any further instruction. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. Review of the Speech Therapist's Swallowing Disorders Treatment Manual used by the ST revealed:..."page 78, The amount of food or drink a person puts into his mouth at one time can affect his ability to swallow safely and easily. The size of the liquid or solid [MEDICATION NAME] may initially be managed or controlled by the clinician and is based on the findings of the MBS (modified [MEDICATION NAME] swallow)...Frequently, the clinician will recommend reduction of the [MEDICATION NAME] size to increase swallowing safely, particularly with patients who are at risk for aspiration. Staff and family members usually require training in this area, especially with individuals who are unable to eat independently...There are three primary ways to alter or control [MEDICATION NAME] size: Reduce the size of the [MEDICATION NAME]; swallow twice per bite or sip; avoid the use of drinking straws..." On [DATE] at 4:15 p.m., Certified Nurse Aide (CNA) "A" stated she regularly provided care to R #1 and that aspiration precautions were located on the resident's nurse aide care plan. CNA "A" stated that R #1 required supervision at meals, which meant to be up in a chair in the dining room at the "feeding table" to prevent aspiration. CNA "A" stated she used a straw when giving R #1 thickened liquids in a cup and that she placed the thickened liquid with the straw on R #1's bedside table so that he could take a drink when staff were not in the room. CNA "A" stated that head of R #1's bed was to be at a 45 degree angle when he drank fluids in bed. CNA "A" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 4:25 p.m., CNA "B" stated that aspiration precautions were located on the resident's nurse aide care plan. CNA "B' stated that aspiration precautions and supervision meant a resident should be up in a chair in the dining room for meals. CNA "B" stated that R #1 had "thickened liquids" and "used a straw a week before he got sick." CNA "B" stated staff kept thickened liquids with a straw on R #1's bedside table so that R #1 could take a drink when staff were not in the room. CNA "B" stated, "He would occasionally pick up his cup and get a drink himself." CNA "B" stated that she had not been inserviced on aspiration precautions by the facility. On [DATE] at 11:45 a.m., Licensed Vocational Nurse (LVN) "C" stated that staff gave R #1 thickened liquids and left the thickened liquid on R #1's bedside table so that he would "have easier access." LVN "C" stated that R #1 would occassionally drink fluids on his own. LVN "C" stated that residents who were at risk of aspiration should not be given a straw to drink fluids, should be sitting up at all times and not be left alone when eating/drinking. On [DATE] at 12:40 p.m., LVN "D" stated if a resident had thickened liquids it was because of "trouble swallowing" and was at risk for "aspiration." LVN "D" stated a telephone order, the MDS and dietary provided information on what type of aspiration precautions residents required, to include the use of straws. LVN "D" stated that she had not been inserviced on aspiration precautions by the facility. LVN "D" stated that R #1 "did not have specific orders" for the use of a straw. On [DATE] at 1:00 p.m., CNA "K" stated "we were taught not to use a straw" with a resident who was an aspiration risk. CNA "K" stated that after giving thickened liquids to a resident in his room, the thickened liquid should be placed out of reach of the resident in the resident's room. On [DATE] at 11:55 a.m., LVN "E" stated if a resident required thickened liquids, that information would be located on that resident's MAR (medication administration record). LVN "E" stated that aspiration precautions (to include the use of straws) would be documented on the resident's consolidated physician orders, dietary flowsheet and the nurse aide care plan. LVN "E" stated the nurses received MBSS results and gave the report to the ST. LVN "E" stated that the ST would then write a telephone order regarding aspiration precautions and notify the physician of the MBSS results. LVN "E" stated a staw should not be used by a resident who was an aspiration risk unless there was a physician's orders [REDACTED]. According to Lippincott's Nursing Procedures, Sixth Edition, page ,[DATE] entitled Impaired Swallowing and Aspiration Precautions:..."Using common swallowing strategies:...Avoid straws. Encourage small sips..." On [DATE] at 12:05 p.m, the Director of Nurses (DON) stated that the facility used Lippincott's as a nursing reference resource. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/Publications/leader/[DATE]f.htm:...(Regarding Speech Language Pathologist documentation requirements) "Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed.... The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques; diet recommendations and modifications; feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding..." R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. The Physician order [REDACTED].#1. R #1's Nursing Assistant Care Plan (NACP) dated [DATE] revealed:..."Oral Problems:...swallowing...Liquids: Honey thick(,) up for all meals or (elevate head of bed)...Diet: Pureed..." The NACP dated [DATE] did not specify to elevate the head of the bed 90 degrees or not to use a straw. R #1's Dietary Card dated [DATE] revealed: pureed; honey textured beverages; plate guard. The Dietary Card did not address the use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (highly involved) with eating. According to the American Speech-Language-Hearing Association on [DATE], http://www.asha.org/docs/html/GL,[DATE].html#sec1.8, ..."Unmanaged oropharyngeal dysphagia is associated with an increased risk of airway obstruction, aspiration pneumonia, death, [MEDICAL CONDITION], and a decreased quality of life..." R #2 R #2's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Significant Change MDS dated [DATE] revealed R #2 coughed or choked during meals or when swallowing medications; had a therapuetic diet; had clear speech; sometimes made self understood; sometimes understood others; had moderately impaired cognition (decisions poor; cues/supervision required); had a memory problem; had inattention and disorganized thinking; was totally dependent on staff for eating, dressing and personal hygiene. R #2's Physician order [REDACTED]. R #2's MBSS results dated [DATE] revealed the following: -Visualized aspirate in the proximal trachea (upper part of the windpipe). -Effective strategies: "controlled sips", cued cough. -Risk of aspiration was moderate due to decreased oral control. -Diet: Mechanical soft, alternate bites/sips, double swallow every one to two [MEDICATION NAME]; thin liquids with "small controlled cup sips". -Downgrade to nectar (by ST) if patient exhibits overt signs/symptoms of penetration/aspiration. -Precautions recommended during oral feeding: Small bites/sips, multiple swallows x double swallow every ,[DATE] [MEDICATION NAME], "positioned upright", "supervised oral feeding", "aspiration precautions". On [DATE] at 4:00 p.m., surveyor inquired about the use of straws with residents who had dysphagia. The ST stated, "Straw use is resident specific" for residents with dysphagia and that "some dysphagia residents can use a straw." The ST stated that R #2, "is no risk with a straw. I have seen his family give him (soda) and hamburgers before and he had no problem. I told the family not to do that." The Speech Therapist (ST) stated that his responsibility was to write a telephone order for straw use, swallowing and feeding techniques, and diets. The ST stated that he did not write telephone orders regarding straw use, and swallowing and feeding techniques for R #2 and that he (ST) should have. After reading again the MBSS results dated [DATE] for R #2 , the ST stated, "Maybe I need to re-evaluate (R #2). I don't remember reading this" (the MBSS recommendations for R #2.) The ST stated he inserviced the nurses in the hallway of the facility to inform them of the type of aspiration precautions R #2 required after the MBSS in [DATE], which included to sit upright for eating and drinking. When surveyor asked the ST for verification of staff inservicing, the ST stated that he did not have any verification. The Physican Order Report dated February 2013 did not include aspiration precautions for R #2. R #2's Speech Therapist Progress Notes on the following dates revealed: -[DATE]: Patient/Caregiver Training: none. -Precautions: May be at risk for aspiration. -[DATE]: Patient/Caregiver Training: Swallow strategies. -Precautions: May be at risk for aspiration. R #2's Speech Therapy Plan of Care dated [DATE] revealed:..."may be at risk for aspiration...choking reported by caregivers..." On [DATE] at 10:22 a.m., R #2's Medical Doctor (MD) "A" stated that it was protocol for the ST to notify him (MD "A") of aspiration precautions that the ST recommended and "I agree with the ST" and "the facility usually calls" to inform MD "A" of MBSS results. MD "A" stated he was not aware that R #2 had a MBSS or the results. MD "A" stated, "Most nursing homes have protocols for aspiration precautions" when asked by surveyor what the definition of aspiration precautions were. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #2's Activities of Daily Living (ADL) Flowsheet dated February 2013 revealed R #2 was independent with eating. The ADL Flowsheet did not indicate the use of a straw. R #2's Nurse Aide Care Plan (NACP) dated [DATE] revealed: Swallowing problem, nectar thickened liquids; "cueing" with tray assistance; dining room at breakfast, noon and evening; mechanical soft diet. The NACP did not indicate the use of a straw. On [DATE] at 9:20 a.m., surveyor observed an opaque colored substance in a clear plastic cup with a straw, sitting on the bedside table of R #2. R #2 was not present in the room. On [DATE] at 12:25 p.m., surveyor observed LVN "D" in R #2's room, with R #2 sitting in a wheelchair. Using a straw, LVN "D" gave R #2 a drink of an opaque colored substance from a clear plastic cup. LVN "D" then walked out of R #2's room and went to her medication cart. LVN "D" then returned to R #2's room and again gave R #2 a drink of an opaque colored substance from a clear plastic cup, using a straw. On [DATE] at 12:40 p.m., after surveyor observation at 12:25 p.m., LVN "D" stated she had given R #2 thickened liquids. LVN "D" stated she used a straw to give R #2 thickened liquids because it was documented by a telephone order, dietary and the MDS that it was safe for R #2 to use a straw. LVN "D" stated R #2 "has thickened liquids because he has trouble swallowing" and that she had not been inserviced by the facility regarding aspiration precautions. LVN "D" stated aspiration precautions and supervision meant to be sure to give a resident thickened liquids if they were ordered. LVN "D" stated that if staff left thickened liquids in the room of R #2, another resident could go into the room and drink the thickened liquid, putting that resident at risk. Review of R #2's telephone orders and consolidated physician orders, MDS and dietary meal card did not address the use of straws. On [DATE] at 1:00 p.m., CNA "K" stated that R #2 "doesn't get a straw" because he "could choke or aspirate." On [DATE] at 12:00 p.m., LVN "F" stated a resident who was at risk for aspiration could get "pneumonia and pass away." On [DATE] at 12:15 p.m., CNA "G" stated a resident who was at risk for aspiration could "aspirate and cut off breathing." On [DATE] at 12:20 p.m., CNA "H" stated a resident who was at risk for aspiration could "choke and get pneumonia." CNA "H" stated, "We were told not to use a straw (with thickened liquids) because it is too thick for the straw." CNA "H" also stated that if a resident was given thickened liquids while in his room, "We take the cup back out of the room because the resident could choke if not supervised." On [DATE] at 12:25 p.m., LVN "I" stated a resident who was at risk for aspiration could get "pneumonia, pleural effusion (abnormal accumulation of fluid in the lungs causing shortness of breath)" and an "obstructed airway." On [DATE] at 12:35 p.m., LVN "J" stated a resident who was at risk for aspiration, liquids "could possibly go into the lungs and die." Review of the facility's Policy Manual\Thickened Liquids dated [DATE] revealed:..."2. Physician Order/Identification...b. Provide therapy interventions if necessary...e. Any resident on thickened liquids will be care planned for risk of dehydration. The additional risk of aspiration should be addressed, as necessary..." On [DATE] at 1:15 p.m., the DON stated, "Anybody with thickened liquids is a swallow precaution." The DON stated that staff were not inserviced on aspiration precautions and that the facility did not have an aspiration precaution policy. The DON stated aspiration precautions were to "Maintain what the MDS says and monitor for classical symptoms" to include "watery eyes." The DON stated the ST determined what aspiration precautions residents required, would write a telephone order for that resident, and the nurses would notify the physician. The DON also stated that if a resident had a MBSS done, the aspiration precautions "would be on the MBSS." The DON also stated that aspiration precautions would be documented on the Care Plan and ADL (activities of daily living) sheet. R #1's Care Plans for facility staff dated [DATE] did not include the use of straws or to be at a 90 degree angle while in bed. R #2's Care Plans for facility staff dated [DATE] through [DATE] did not include use of straws. R #1's Activities of Daily Living (ADL) Flowsheet dated [DATE] revealed R #1 frequently required limited assistance (R #1 was highly involved) with eating. There were no aspiration precautions listed for R #1. R #2's ADL Flowsheet dated February 2013 revealed R #2 was independent with eating. There were no aspiration precautions listed for R #2. On [DATE] at 12:05 p.m., the DON stated "I agree to disagree" when asked if any resident was at risk for harm as a result of the IJ. The DON stated that the IJ came about because "You (surveyor) said you (surveyor) identified a breakdown in communication." The DON stated that the Therapy Corporate Consultant was responsible for the Speech Therapist and the resources available to the facility were consultants, doctors in different specialties and inservices. The DON stated she ensured staff were competent in their skills by inservicing and using "check-off lists." Review of the facility's undated Nurse Orientation Checklist revealed the following items: "Therapy Services" and "Observation of Meals". Review of the facility's undated Nursing Assistant Skills Review revealed the following item: "Feeding Techniques". On [DATE] at 11:45 a.m., an IJ was identified and the DON and Administrator were informed at 11:45 a.m. of the IJ due to the above failures. On [DATE] at 7:00 p.m., the facility submitted a second Plan of Removal which contained the following: -Problem: Lack of system to communicate swallowing precautions to clinical staff for residents on thickened liquids with risk for aspiration. -Plan: 1. All residents on thickened liquids will be screened by the SLP (Speech Language Pathologist) to validate current aspiration risks and appropriate precautions taken to include: * Special interventions (i.e. head of bed elevated, chin tuck, appropriate liquid consistency, appropriate diet consistency, straw restrictions). * Any discrepencies will be identified and addressed through MD with SLP treatments as needed. Person respsonsible: SLP. 2. Any physician orders [REDACTED]. Person responsible: SLP. 3. All available clinical staff (RNs (Registered Nurses), LVNs, CNAs, CMAs (Medication Aides), Restorative CNA) will receive in-service training by DON/Designee on [DATE] and remaining staff will not be allowed to work until re-inservicing. * Signs/symptoms of aspiration. * Use of CNA Care Plan related to communication of aspiration precautions, thickened liquids, diet consistency. * Therapy communication form to ensure therapy is aware of changes in swallowing ability in any resident. The above listed training will be part of newly hired staff orientation. Person responsible: DON. 4. SLP will clearly communicate specific aspiration precautions for all residents who receive thickened liquids through a telephone order detailed with swallowing precautions, and specific aspiration precautions. Person responsible: SLP. 5. DON/ADON (Assistant Director of Nurses) will ensure all residents identified from the telephone order as aspiration risk will have (their) Care Plan and CNA care plan updated with current aspriration precautions to include liquid consistency, diet consistency and aspiration precautions. Person responsible: DON. 6. DON/Designee will continue to ensure that (the) Dietary Manager receives a current list of all residents on thickened liquids with aspiration precaution recommendations from SLP (i.e. liquid consistency, diet consistency). Person responsible: DON. 7. Thickened liquid consistency will be listed on the residents MAR (medication administration record) for identification during med pass, to include swallowing precautions. Person responsible: DON. 8. DON/ADON will ensure that MAR indicated [REDACTED]. Person responsible: DON. 9. A QA (Quality Assurance) meeting was held today with the Medical Director at the facility, which included the Administrator, the DON, the SLP and the Rehab Manager. Person responsible: Administrator. 10. The Medical Director was informed today of the IJ status being called today [DATE]. Person responsible: Administrator. 11. If Physician orders [REDACTED]. Person responsible: DON. 12. The charge nurses will be responsible to notify family members and residents of speech therapist orders including swallowing precautions. Person responsible: DON. 13. This Plan of Removal is the guideline and interventions on swallowing precautions. Person responsible: Administrator. On [DATE], the facility conducted an inservice which included the following information:..."Thickened fluids are not left at (the) bedside; thickened liquid residents do not use a straw unless ordered...If a resident is thickened can not eat alone..." On [DATE] at 12:10 p.m., the Administrator stated "I do not feel there was a risk of harm" for any resident as a result of the IJ. The Administrator stated that "Staff policies and procedures, Quality Assessment and Assurance (QA&A), rounds, resident interviews and staff training" were the facility procedures to ensure the nursing needs of the residents were met. The Administrator stated that aspiration precautions for R #1 and R #2 were not addressed by the QA&A; staff were inserviced to ensure competency; and the policies and procedures were evaluated annually by the QA&A committee with the Corporate Office giving "revisions". The Administrator stated the IJ came about "through the complaint investigation" and "No other reason". The Administrator stated that she was "ultimately" responsible for the Speech Therapist and the DON was responsible for the nursing department. Through observations, interviews and record reviews, the survey team determined that the use of straws, staff inservicing, and new Care Plans documented in the facility's Plan of Removal were implemented. On [DATE] at 12:30 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Review of the facility's Thickened Liquids list dated [DATE] revealed 26 residents were at risk of aspiration. On [DATE] at 12:30 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information regarding aspiration precautions. None was provided.

Based on observation, interview and record review the facility failed to provide an environment that was free from accident hazards over which the facility had control for one Resident (R #1) of seven residents reviewed for accidents and injuries. R #1 received a second degree burn (partial thickness loss of the superficial skin layer causing pain, redness, swelling, and blistering) from coffee that was accidentally spilled by Certified Nurse Aide (CNA) "B" onto R #1's left thigh while lying in bed. Failure to put effective interventions into place to prevent burns from coffee that has the potential to cause second degree burns could affect the 163 residents in the facility that received meals prepared in the facility's kitchen. Finding were: Review of R #1's Face Sheet dated 05/01/12 revealed an admitted 07/05/11. Review of R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1's [DIAGNOSES REDACTED]. The MDS revealed: R #1 was totally dependent on staff to provide Activities of Daily Living which included bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; R#1 was able to feed himself but required set-up assistance from staff; R #1 was able to recall the correct year, month and day of the week. Review on 05/08/12 of R #1's Telephone Orders dated 04/28/12 revealed to apply Silvadene (cream used for burns) to R #1's left outer thigh every day and as needed - the order was discontinued on 04/30/12; 04/30/12 revealed a current Telephone Order to cleanse the left outer thigh with normal saline, pat dry and apply Triple Antibiotic Ointment every day. Review on 05/09/12 of R #1's Nurses Notes revealed on 04/28/12 at 6:20 a.m. a CNA reported that coffee was spilled onto R #1's thigh after the CNA moved the overnight table and an ice pack was applied to the area. The next entry dated 04/29/12 at 10:45 a.m. revealed area red and blisters opened to left thigh. Review on 05/09/12 of the Incident Report dated 04/28/12 revealed CNA "B" spilled coffee onto R #1's left thigh while he was lying in bed, causing a reddened area. On 05/08/12 at 3:10 p.m., R #1 stated that "coffee was accidentally spilled onto my left thigh about two weeks ago by a CNA who brought me coffee while I was lying in bed. I was burned, developed blisters and had some pain but it didn't last long. I didn't need to take pain medication." During an observation on 05/08/12 at 3:15 p.m. with Licensed Vocational Nurse (LVN) "A", surveyor observed the following to R #1's left outer thigh: an area approximately seven inches long and three inches wide that was dry, pink in color and surrounded by dark brown colored tissue. LVN "A" stated that R #1 had received a second degree burn approximately two weeks ago from hot coffee being spilled onto him by a CNA while R #1 was lying in bed. On 05/08/12 at 4:10 p.m., the Director of Nurses (DON) stated that R #1 had received a second degree burn to his left thigh from a CNA who served hot coffee to R #1 in his room and accidentally spilled it onto him while he was lying in bed on 04/28/12. The DON stated that after the incident, the staff were inserviced to stabilize the residents food trays/drinks on their bedside tables before serving the drinks to the residents to avoid spilling hot liquids onto the residents. The DON stated that the facility did not assess the temperature of the coffee that was served to the residents. During an observation on 05/09/12 at 11:45 a.m., the Food Service Supervisor (FSS) measured the temperature of the coffee that was in the commercial coffee brewing machine, using the facility's food temperature thermometer. The FSS poured coffee from the coffee brewing machine into a coffee cup that was used to serve the residents; the measured temperature was 180 degrees Fahrenheit (F). The FSS stated that after the coffee was brewed in the brewing machine, it was then poured into a carafe and placed in the dining room so that it could be served to the residents. She stated the staff then poured coffee from the carafe into the facility's coffee cups and served it to the residents. The FSS measured the temperature in the carafe at 161.8 degrees F. The FSS stated that a second degree burn could result from a temperature of 140 degrees F. Surveyor then observed residents being served coffee from the carafe in the dining room. On 05/09/12 at 11:45 a.m., the FSS stated that she was not aware that R #1 received a second degree burn from hot coffee being spilled onto him and had not put anything into place to prevent it from happening again. On 05/09/12 at 12:20 p.m., Surveyor called CNA "B" by telephone but there was no answer. On 05/09/12 at 1:45 p.m., CNA "A" stated that he felt the coffee that was served from the kitchen was "too hot" and that he did not allow residents in the dining room to get their own coffee from the carafe because he felt there was a risk that a resident may get burned. CNA "A" stated that he had not told the administration of his concern. On 05/09/12 at 3:25 p.m., the FSS stated that the staff utilized the coffee pot in the Occupational Therapy (OT) Kitchen to serve the residents coffee when the kitchen staff had not yet prepared hot coffee for the residents. Using the facility's food thermometer, the FSS measured the temperature of the hot water that was brewed in the coffee pot in the OT Kitchen at 159 degrees F after it was poured into a cup that was used to serve the residents. According to the State Operations Manual, Appendix PP, 42 CFR 483.25(H) (1) AND (2) ACCIDENTS AND SUPERVISION, Physical Plant Hazards, a third degree burn can occur after a resident's skin comes into contact with water at a temperature of 155 degrees F after one second. Record review of the facility's Resident Rights Policy dated 7/2006 revealed residents have the right to be safe in the facility. Review of the facility's CMS-672 dated 05/11/12 revealed 163 residents received meals prepared from the facility's kitchen. During the exit conference on 05/09/12 at 4:00 p.m. the facility was given the opportunity to provide additional information or documentation. The facility did not provide additional information or documentation.